mss 


Methods  of  Filling  Teeth. 


An  Exposition  of  Practical   Methods  which  will  Enable 
THE  Student  and  Practitioner  of  Dentistry  Suc- 
cessfully    to     Prepare    and     Fill    all 
Cavities  in  Human  Teeth. 


BY 

RODRIGUES  OTTOLENGUI,  M.D.S. 


SECOND  EDITION. 


with 

TWO  HUNDRED  AND  SEVENTY-THREE  ILLUSTRATIONS 

Giving  Exact  Representations  ol  all  Classes  of  Cavities 
and  their  Management. 


PHILADELPHLA.  : 

THE  S.  S.  WHITE  DENTAL  MFG.  CO. 

LONDON: 

CLAUDIUS  ASH  &  SONS,  LIMITED. 

1899. 


Copyright,  1891,  by  R.  Ottolengui. 


Copyright,  1898,  by  The  S.  S.  White  Dental  Mfg.  Co. 


Entered  at  Stationers'  Hall,  London. 


Preface  to  First  Edition. 


THERE  are  already  so  many  text-books  that  the  question  might 
be  asked,  "Why  another  ?  "  My  reply  gives  my  excuse  for 
my  intrusion.  Without  designing  to  criticise  the  methods  of 
other  writers,  I  would  yet  call  attention  to  the  fact  that  many  have 
given  us  works  which  are  largely  compilations.  These  authors  have 
seemed  loath  to  leave  anything  unsaid  which  is  pertinent  to  their 
subjects.  In  their  efforts  to  be  fully  comprehensive  they  have  quoted 
freely  from  others,  giving  pros  and  cons  by  men  of  equal  authority, 
till  the  student  who  is  a  beginner  is  bewildered  in  his  effort  to  choose. 
To  avoid  this,  I  decided  to  describe  in  my  book  only  such  methods  as 
I  have  myself  tested,  believing  that  the  student  will  be  more  benefited 
by  adopting  a  single  successful  mode  of  practice  than  by  essaying  the 
various  methods  of  many  men. 

This  has  involved  a  two-fold  result.  First,  and  most  important,  the 
teaching  becomes  dogmatic. 

The  charge  has  been  freely  made  that  "writers  are  not  skillful 
dentists."  This  is  because  theory  and  practice  are  so  often  at  vari- 
ance. I  have  endeavored  to  write  a  work  which  would  be  as  practical 
as  words  could  make  it.  There  is  not  a  case  described  that  has  not 
occurred  in  my  practice.  There  is  not  a  method  advocated  that  I 
have  not  tested. 

The  second  result  is  that  I  do  not  give  detailed  directions  for  carrying 
out  methods  which  I  have  not  attempted.  This  of  course  makes  the* 
book  incomplete  from  that  standpoint  ;  but  I  prefer  this  to  being 
quoted  as  authority  for  that  which  I  have  not  myself  tested,  as  too 
many  have  been  already.  As  an  example  of  such  omission,  it  will  be 
observed  that  I  do  not  describe  methods  of  using  non-cohesive  gold 
foil.  I  can  only  say  in  defense  that  I  have  never  used  non-cohesive 
foil,  and  let  that  excuse  my  not  treating  of  it.  I  will  reiterate,  how- 
ever, what  I  say  in  the  body  of  the  book,  that  I  have  never  seen  any 


iv  PREFACE   TO  FIRST  EDITION. 

need  of  it,  nor  found  any  man  who  could  prove  its  necessity.  I  do 
not  think  my  patients  have  suffered  because  of  my  lack  of  knowledge 
in  this  direction. 

Because  of  the  fact  that  my  work  first  appeared  in  serial  in  the 
Dental  Cosmos,  I  am  enabled  here  to  reply  to  one  or  two  criticisms 
which  have  been  printed  in  society  reports.  One  gentleman  quotes 
me  as  advocating  a  broad  contact-point  in  approximal  fillings.  In 
this,  if  he  was  correctly  reported,  he  has  misrepresented  me.  My 
advocacy  of  such  a  contact  is  in  connection  with  a  specified  condition 
only,  and  the  position  which  I  take  is  one  which  I  am  ready  to  defend 
clinically  or  otherwise  at  any  time.  This  would  be  an  inappropriate 
place  to  discuss  it. 

Another  gentleman  is  reported  to  have  said  that  I  advise  students 
to  have  as  few  instruments  as  possible,  and  that  I  myself  fill  teeth  with 
a  broken  instrument.  The  first  statement  is  accurate.  I  think  that 
a  man  beginning  the  practice  of  dentistry  should  not  purchase  many 
instruments  until  he  has  had  the  experience  which  will  lead  him  toward 
a  wise  choice  of  such  an  assortment  as  will  best  suit  his  individual 
peculiarities  and  requirements.  The  second  statement  is  inaccurate, 
I  simply  say  that  a  good  filling  may  be  inserted  with  a  broken  instru- 
ment. The  point  here  was  in  reference  to  whether  the  point  of  a 
plugger  should  be  serrated  or  smooth.  A  broken  point  is  neither 
the  one  nor  the  other,  yet  may  be  a  good  point.  While  it  is  not  my 
practice  to  fill  teeth  with  a  broken  instrument,  as  suggested,  I  could 
easily  demonstrate  that  as  good  a  filling  can  be  inserted  in  that  way 
as  with  the  best  new  plugger.    Again  I  say  it  is  the  man,  not  the  tool. 

Let  me  say  here,  as  I  have  said  in  the  body  of  this  work,  I  do  not 
make  any  broad  claims  for  originality  in  connection  with  the  methods 
described.  If  there  is  any  originality  at  all,  it  is  in  the  method  of 
teaching,  rather  than  in  the  thing  taught.  To  offer  the  profession, 
and  especially  those  just  entering  it,  a  work  advocating  methods 
entirely  my  own  would  be  to  ask  the  adoption  of  modes  of  practice 
not  in  common  use,  and  therefore  not  sufficiently  well  tested. 

I  have  no  sympathy  with  those  who  are  constantly  crying  out, 
"That  is  my  method;  I  invented  it.''  The  chief  interest  to  the 
student  must  always  be  in  a  thorough  knowledge  of  the  method  itself. 
rather  than  in  the  name  of  its  originator. 


PREFACE    TO  FIRST  EDITION.  V 

To  those,  therefore,  who  will  find  a  description  of  their  original 
methods  in  my  book  I  have  only  to  say,  "  Gentlemen,  I  thank  you 
for  what  you  have  taught  to  me,  and  am  now  in  turn  trying  to  teach 
it  to  others."  I  wish  also  to  extend  my  heartiest  gratitude  to  the 
hundred  or  more  dentists  of  this  country  and  Europe  who,  though 
strangers  to  me,  have  written  me  kindly  letters  of  approval  during 
the  progress  of  this  work.  Many  times  have  such  letters  proved  a 
solace  to  me  when  hand  and  brain  were  tired,  and  so  have  been  an 
incentive  to  continue.      I  thank  them. 

RoDRiGUEs  Ottolengui,  M.D.S. 

115  Madison  Avenue,  New  York,  September  i,  1892. 


Preface  to  Second  Edition. 


IT  is  just  six  years  since  the  preface  to  the  first  edition  of  this 
work  was  written,  and  now  a  revised  or  second  edition  is  ready 
for  publication. 

During  this  lapse  of  time  what  advances  have  been  made  in  our 
profession?  To  know  certainly  what,  if  any,  theories  have  been 
advanced  which  would  necessitate  a  change  in  the  text,  it  has  been 
necessary  to  review  all  that  has  been  printed  touching  the  subject, 
either  in  text-books  or  in  our  magazines.  This  has  been  done  at  a  cost 
of  months  of  labor,  during  which  '  *  spare  time' '  has  been  devoted  to 
this  reading.  In  a  few  instances  the  teaching  of  other  men  or  of 
office  experience  has  caused  me  to  alter  passages  or  to  add  to  the 
text.  When  no  changes  have  been  made  the  text  has  been  left  in 
its  original  form,  not  to  avoid  the  work  of  rewriting,  but  because 
nothing  in  the  literature  or  in  my  own  experience  has  seemed  to 
render  a  new  teaching  necessary.  Thus  the  book  may  be  considered 
throughout  as  representing  the  views  which  I  hold  to-day. 

It  will  probably  be  noted,  with  surprise,  that  no  mention  of  cata- 
phoresis  is  made  in  this  edition.  This  is  not  because  I  do  not  ap- 
preciate the  importance  of  this  aid  to  the  dentist,  but  rather  because 
I  hesitate  to  advocate  methods  which  have  not  yet  been  finally 
adopted.  Cataphoresis  is  yet  in  its  infancy,  as  appHed  to  dentistry, 
and  methods  now  in  vogue  may  become  obsolete  within  a  year. 
^Perhaps  should  a  third  edition  of  this  work  ever  be  offered,  it  may  be 
possible  then  to  describe  definite  methods  sanctioned  by  universal 
adoption. 

R.  Ottolengui,  M.D.S. 

115  Madison  Ave.,  New  York,  September  i,  1898. 


CONTENTS. 


CHAPTER    I. 

PAGE 

General  Principles  involved  in  the  Preparation  of  Cavities — 
Removal  of  Decay — Retentive  Shaping — Intentional  Exten- 
sion— Directions  for  Forming  Cavity-Borders — Shaping 
Enamel  Margins i 

CHAPTER    11. 

General  Principles  involved  in  the  Filling  of  Teeth — Methods 
of  Keeping  Cavities  Dry — The  Rubber-Dam — Ligatures — Clamps 
— Leakage — The  Napkin — Chloro-percha — Wedges  vs.  Separa- 
tors— The  Uses  and  Dangers  of  Matrices 28 

CHAPTER    II  L 

The  Uses  of  Various  Filling-Materials— Methods  of  Manipula- 
tion— Materials  of  Minor  Value— Gutta-percha — Oxychlo- 
ride  of  Zinc — Oxyphosphate  of  Zinc — Amalgams — Copper  Amal- 
gam— Gold 49 

CHAPTER    IV. 

The  Relative  Values  of  Contour,  and  Flat  or  Flush  Fillings 
— The  V-Shaped  Space  in  its  Relation  to  the  Gingiva — The 
Restoration  of  Superior  Lateral  Incisors — Slight  Contours 
— Regulation  of  Teeth  by  Contour  Fillings — Departure  from 
Original  Form — True  Contouring— Treatment  of  Masticating 
Surfaces — Contouring  with  Gold — With  Amalgam — With  the 
Plastics  in  connection  with   Gold   Plate — Use  of  Screws — 

Cases  from  Practice  requiring  Odd  Methods 89 

vii 


via  CONTENTS. 

CHAPTER    V. 

PAGE 

Special  Principles  involved  in  the  Preparation  of  Cavities, 
and  in  the  insertion  of  killings — consideration  of  approxi- 
MAL  Cavities  IN  Incisors — In  Cuspids — In  Bicuspids — In  Molars.  114 

CHAPTER    VI. 

Special  Principles  involved  in  the  Preparation  of  Cavities 
AND  THE  Insertion  of  Fillings — Cavities  in  the  Masticating 
Surfaces — Incisors — Treatment  of  Imperfections — Of  Frac- 
tures— Of  Abrasions — Of  Malformations — Cuspids — Bicuspids 
— Molars — Oxyphosphates  in  Combination  with  Gold — Uniting 
Teeth  by  Bar  and  Filling 136 

CHAPTER  VII. 

Special  Principles  involved  in  the  Preparation  of  Cavities  and 
THE  Insertion  of  Fillings — Sensitiveness  at  the  Tooth-Neck 
— Erosion — Green-Stain — True  Caries — Festoon  Cavities — 
The  Labial  Surface — The  Palatal — The  Lingual — Buccal 
Cavities — Temporary  Fillings — The  Finishing  of  Fillings 163 

CHAPTER    VIII. 

Methods  of  Filling  the  Canals  of  Pulpless  Teeth — A  Study  of 
Tooth-Roots— Methods  of  Gaining  Access  to  and  Preparing 
Canals — Methods  of  Cleansing  Root-Canals — When  and  How 
TO  Fill  Root-Canals 190 

Index 217 


METHODS  OF  FILLING  TEETH. 


CHAPTER    I. 

General  Principles  involved  in  the  Preparation  of  Cavities- 
Removal  OF  Decay — Retentive  Shaping — Intentional  Extension- 
Directions  FOR  Forming  Cavity-Borders — Shaping  Enamel  Mar- 
gins. 

Now  that  the  dentist  is  no  longer  to  be  denominated  the  ' '  knight  of 
the  forceps, "  it  is  fundamentally  essential  that  he  who  would  become 
a  conscientious  practitioner  should  be  able  to  determine  whether  a 
tooth  be  salvable  by  the  insertion  of  a  filling  ;  to  decide  which  of  the 
many  materials  now  in  use  will  best  attain  the  end  in  view  ;  to  prop- 
erly prepare  the  cavity  for  the  reception  and  continued  retention  of 
the  filling,  and  be  capable  of  scientifically  and  skillfully  placing 
it  so  that  it  will  be  as  nearly  perfect  as  the  attending  conditions 
will  permit.  This  much  has  been  accomplished  by  a  goodly  number 
of  the  dentists  of  the  past  and  present.  Something  more  will  be 
expected  of  the  dentist  of  the  future.  He  will  be  asked  to  abandon 
the  assertion,  "Madam,  your  tooth  has  decayed  around  my  filling, 
but  the  filling  was  all  rights 

Undoubtedly  there  are  teeth  in  which  it  may  be  impossible  to 
prevent  recurrence  of  decay,  but  it  is  equally  true  that  in  too  many 
cases  when  the  ' '  tooth  decays  around  the  filling' '  the  filling  was  not 
"all  right."  It  is  opportune,  therefore,  to  discuss  these  questions 
more  in  detail  than  has  been  done  heretofore. 

Those  whose  fillings  are  frequently  returned  to  them  in  a  leaky 
condition  are  compelled  to  adopt  one  of  two  propositions  :  Either 
their  work  is  inefficient,  or  else  the  teeth  upon  which  they  have 
operated  are  of  poor  quality.  It  is  but  human  to  lean  toward  the  latter 
explanation.  The  position,  however,  is  rarely  tenable.  The  argu- 
ment used  is  this  :  "  If  the  tooth  decayed  when  it  was  perfect,  why 
should  it  not  do  so  after  it  has  been  filled  ?    I  cannot  be  expected  to  build 


2  METHODS  OF  FILLING   TEETH. 

better  than  did  the  Creator. ' '  This  sentiment  was  loudly  applauded 
at  a  national  meeting,  leaving  the  impression  upon  the  mind  of  him 
who  analyzed  the  situation  that  there  were  many  present  anxious  to 
adopt  this  specious  excuse  for  the  failures  which  had  attended  their 
efforts.  The  fallacy  lies  in  this  :  While  it  is  perhaps  true  that  no 
material  exerts  any  therapeutic  influence  beyond  the  mere  mechanical 
stopping  of  a  hole  and  restoration  of  contour,  it  is  also  true  that, 
given  a  tooth,  and  certain  conditions  under  which  it  is  attacked  by 
caries,  the  caries  will  occur  invariably  at  a  specified  situation.  There- 
fore, when  the  cavity  is  filled  scientifically  the  tooth  is  safer  than  ever, 
because  the  vulnerable  point  is  now  occupied  by  a  material  which 
will  resist  destruction  by  caries.  If  decay  occurs  along  margins,  it  is 
because'  those  margins  were  improperly  made  either  as  to  shape  or 
position,  or  else  because  the  filling  was  unskillfully  inserted  or 
finished.  An  ideally  completed  filling  is  one  which  is  given  as  high  a 
polish  as  the  material  used  will  permit.  Those  who  argue  for  ' '  dull 
finish,"  because  less  conspicuous,  forget  that  "high  polish"  means 
smoothness,  which  quality  is  a  prerequisite. 

The  student  watching  his  preceptor  is  almost  invariably  impressed 
with  the  idea  that  only  a  few  principles  are  involved,  and  that  the 
operation  of  filling  a  tooth  is  purely  mechanical.  As  soon  as  he 
acquires  the  knack  of  packing  gold  and  producing  a  polished  surface 
afterward,  he  considers  that  ' '  he  knows  it  all. "  It  is  only  after 
several  years  of  bitter  experience  at  refilling  teeth  for  his  own 
patients,  that  he  begins  to  suspect  that  perhaps  there  is  more  in  this 
branch  of  dentistry  than  his  mind  had  grasped.  Let  us  now  con- 
sider the  subject  in  detail,  from  the  point  of  view  that  there  is  more 
involved  in  it  than  mere  mechanics. 

General  Principles  involved  in  the  Preparation  of 

Cavities. 

Removal  of  Decay. — When  a  cavity  has  been  properly  prepared, 
the  tooth  is  half  filled.  The  most  beautifully  polished,  soUd,  well- 
formed  filling  will  fail  if  the  cavity  has  not  been  skillfully  shaped. 

To  the  mind  of  the  layman  it  would  seem  idle  to  discuss  the  pro- 
priety of  leaving  any  decay  in  a  cavity.  It  is  not  uncommon  to  have 
a  mother  say,  ' '  Doctor,  please  be  sure  to  take  all  the  decay  out,  as  I 
don' t  want  Willie' s  tooth  to  trouble  him  again. ' '  To  her  mind,  safety 
lies  in  thorough  cleansing.  It  seems  a  rational  proposition,  yet  it  has 
been  argued  by  high  authorities  that  there  are  frequently  occurring 
cases  where  it  is  best  not  to  remove  all  the  decayed  dentine. 

This  is  a  grave  error.  With  rare  exceptions  it  is  imperative  that 
every  trace  of  caries  should  be  obliterated.  The  tooth  about  to 
receive  a  filling  should  be  as  wholly  healthy  as  it  can  be  made. 


REMOVAL  OF  DECAY.  3 

It  has  been  claimed  that  decay  covering  a  pulp  may  be  left  in  place 
and  sterilized  with  safety  and  advantage.  This  sterilizing  is  usually 
done  at  the  sitting  at  which  the  filling  is  placed.  I  have  followed  this 
advice  in  a  few  cases,  where,  in  the  front  of  the  mouth,  it  seemed  best  to 
take  every  precaution  to  avoid  destruction  of  the  pulps  and  consequent 
discoloration.  In  every  case  I  have  afterward  removed  the  fillings, 
because  of  a  bluish  appearance  which  subsequently  presented,  showing 
that  despite  the  fact  that  the  edges  were  yet  perfect,  decay  was  pro- 
gressing internally.  This  shows  that  a  perfect  gold  filling  will  not  stop 
decay  if  carious  dentine  is  left  in  the  cavity.  Experiments  made  by 
Professor  Miller  are  in  harmony  with  this  experience,  since  he  shows 
that  the  germicides  upon  which  most  reliance  has  been  placed  are  in- 
effectual unless  left  in  a  cavity  much  longer  and  in  greater  quantity 
than  has  been  our  practice.  When  our  chemists  shall  have  dis- 
covered for  us  a  sterilizing  agent  the  use  of  which  will  assure  us  of  a 
discontinuance  of  carious  action,  in  already  carious  dentine,  then,  and 
not  till  then,  will  there  be  any  argument  worth  listening  to  against  the 
assertion  that  it  is  ?naipractice  to  Jill  over  decay. 

Indeed,  in  the  light  of  present  knowledge,  the  dentist  must  not 
only  eradicate  the  truly  carious  dentine,  but  he  should  also  deal  with 
the  zone  of  "  infected  "  dentine  which  lies  adjacent. 

TofuUy  comprehend  this  term,  "  '  infected'  dentine,"  which  I  intro- 
duce for  the  consideration  of  scientific  and  prophylactic  practitioners 
of  the  future,  we  must  understand  the  causes  which  produce  dental 
caries,  as  well  as  the  modus  operandi  of  the  agencies  at  work.  With- 
out entering  into  a  technical  discussion  of  the  various  theories  which 
have  been  advanced,  I  may  say  that  I  at  present  accept  that  expla- 
nation of  dental  caries  which  has  been  demonstrated  so  admirably  by 
Dr.  J.  Leon  Williams,  a  brief  summary  of  which  is  as  follows  : 

Human  enamel  is  composed  of  a  series  of  globular  bodies,  super- 
imposed the  one  upon  the  other,  these  bodies  and  the  rods  them- 
selves being  held  together  by  a  cement-substance.  In  the  production 
of  dental  caries,  first,  there  appears  imposed  upon  and  firmly 
attached  to  the  non-carious  surface  of  enamel  a  felt-like  stratum  of 
micro-organisms.  Second,  these  micro-organisms  excrete  a  virulent 
acid,  which  has  the  power  to  dissolve  the  cement-substance,  which 
normally  binds  the  enamel-rods  and  their  formative  sections,  the 
globular  bodies.  Third,  this  acid  dissolution  primarily  follows  the 
spaces  between  the  rods  ;  thus,  to  use  an  analogy,  boring  shafts  or 
well  holes,  and  thereby  offering  entrance  to  the  multiplying  bacterial 
cells,  which,  following  the  course  marked  out  with  their  own  excre- 
tions, grow  from  the  surface  internally,  penetrating  the  enamel  as 
rapidly  as  the  dissolution  of  the  cement-substance  will  permit. 
Subsequently,    and    to    some   extent   coincidentally,    the    excreted 


4  METHODS  OF  FILLING  TEETH. 

acid  attacks  the  cement-substance  of  the  rods  themselves,  separat- 
ing them  into  their  original  formative  sections. 

The  penetration  of  this  acid  solvent  is  greatly  in  advance  of  the 
inroads  of  actual  decay,  and  the  dentine  itself  may  be  affected,  and 
perhaps  infected,  while  there  might  be  but  slight  evidence  of  decay 
at  the  external  surface  of  the  enamel. 

It  may  be  well  to  explain  clearly  my  differentiation  between 
"  affected  "  and  "  infected."  I  conceive  the  tooth-substance  to  be 
"  affected"  when  the  acid  excretion  of  micro-organisms  has  dissolved 
the  cement-substance,  however  slightly  :  when  the  dissolution  has 
progressed  further,  so  that  shafts  have  been  bored,  into  which 
bacterial  cells  have  penetrated,  the  tissue  is  "  infected."  When  the 
enamel-rods  have  been  separated  into  their  original  globular  bodies, 
we  have  carious  tissue.  The  lines  of  positive  demarcation  between 
these  three  stages  cannot  be  certainly  indicated,  as  the  whole  is  a 
progressive  disorganization.  We  may  well  remember,  however,  that 
all  tooth  bone,  adjacent  to  caries,  is  affected  tissue,  and  it  would  be 
wise  to  give  germicidal  treatment  prior  to  filling.  Where  we  meet 
dentine  which  is  changed  in  character,  though  not  perhaps  absolutely 
carious,  such  as  that  which  has  been  termed  softened  dentine,  we  may 
henceforth  consider  it  to  be  "  infected,"  and  if  in  a  special  case  we 
deem  it  unwise -to  remove  this  infected  tissue^  we  should  remember 
that  it  contains  the  agencies  which  produce  decay,  and  at  least  we 
should  treat  it  with  a  reliable  germicide. 

Infected  dentine  requiring  special  treatment  is  always  present  in 
those  teeth  from  which  we  remove  carious  dentine  in  leathery  layers. 
To  excavate  such  a  cavity,  use  spoon  excavators  only.  Never 
employ  a  hatchet,  or  a  hoe,  or  an  engine-bur,  unless  needed  for 
shaping  after  the  decay  has  been  removed.  With  a  spoon  begin  at 
a  point  farthest  away  from  the  pulp,  and  gently  lift  the  outer  edge  of 
a  layer.  Having  thus  disengaged  it,  proceed  to  lift  it  around  its  whole 
circumference,  and  then  work  gradually  toward  the  center  till  it  can 
be  taken  out  of  the  cavity.  Repeat  this  as  often  as  a  layer  can  be 
started  at  its  circumference.  As  soon  as  the  last  distinct  layer  has 
been  removed,  scrape  all  the  walls  vigorously,  removing  even  the  soft- 
ened dentine  which  may  be  clinging  to  them.  The  cavity  will  now  be 
clean,  but  the  bottom  of  it  will  be  soft.  Still  using  the  spoon,  scrape 
the  bottom  very  gently,  starting  at  the  circumference  and  approach- 
ing the  center,  removing  all  small  particles  which  may  be  thus  disen- 
gaged, without  actually  cutting.  A  reliable  germicide  should  now  be 
used  on  cotton,  the  cavity  sealed  with  a  phosphate  cement,  and  so  left 
.  for  two  or  three  days,  when  the  filling  may  be  inserted  with  safety. 

Infected  dentine  may  be  found  beneath  other  than  leathery  decay. 
When  it  is  found  underlying  decalcified  enamel,  the  enamel  will  come 


RETENTIVE  SHAPING.  5 

away  as  a  white,  chalky  powder,  and  the  dentine  beneath  need  only  be 
removed  as  required  for  the  retention  of  the  filling.  This  condition 
is  rarely  observed  except  under  "green-stain,"  and  the  destruc- 
tion is  a  decalcification,  rather  than  true  caries.  A  corundum  stone 
should  be  used  to  remove  the  stain,  when  the  decalcified  enamel  will 
readily  be  distinguished  by  its  chalk  color.  The  dentine  beneath  is 
infected,  but  as  the  destruction  is  superficial  there  is  little  risk  of 
exposing  the  pulp,  for  which  reason  no  special  caution  is  needed 
beyond  the  usual  care  when  operating  on  healthy  dentine,  not  to  cut 
deeper  than  is  actually  necessary  to  correctly  shape  the  cavity.  It 
may  be  said  in  passing  that  this  decalcification  of  enamel  due  to  or 
accompanying  "green-stain  "  is  usually  associated  with  highly  sensi- 
tive dentine.  This  is  fair  presumptive  evidence  that  the  dentine  is 
undergoing  a  change. 

There  is  a  class  of  teeth  which  appear  stained,  in  which  a  seeming 
decalcification  of  enamel  will  be  found,  which  teeth,  however,  re- 
quire the  most  conservative  attention  and  skillful  treatment.  These 
teeth  show  brownish  or  otherwise  discolored  spots,  usually  extending 
from  one  of  the  lateral  surfaces  up  to,  and  sometimes  into  the 
occlusal.  These  are  not  stains  which  are  removable,  but  are  de- 
fectively calcified  tooth  substance.  Occasionally  such  a  spot  will  be 
found  in  a  perfectly  shaped  tooth,  the  usual  enamel  lustre  being 
present  ;  again  the  surface  will  be  irregular  but  still  somewhat 
polished.  If  these  spots  are  entered  with  a  bur,  the  enamel  and  sub- 
jacent dentine  will  be  found  chalky,  and  often  very  extensive  cutting 
will  be  needed  to  reach  firm  tissue.  If  a  filling  is  required  all  this 
improperly  calcified  tissue  must  be  removed  until  strong  margins  are 
obtained.  Unless  absolutely  necessary,  however,  it  is  usually  best 
to  leave  such  places  undisturbed,  because  not  infrequently  they 
appear  to  be  immune  to  caries  for  years,  even  though  neighboring 
teeth  may  be  badly  affected. 

Retentive  shaping. — The  cavity  cleansed  of  decay,  the  next  impor- 
tant object  is  to  so  shape  it  that  the  filling  cannot  be  dislodged  mechan- 
ically after  it  has  been  inserted.  To  accomplish  this  sometimes  taxes 
the  utmost  ingenuity  of  the  most  experienced,  so  that  binding  rules 
cannot  be  formulated  to  cover  all  conditions.  It  will  therefore  be 
best,  in  order  to  describe  methods  covering  a  wide  field,  to  take  up 
individually  the  more  common  cavities,  but  before  proceeding  to  that 
discussion  I  shall  present  here  a  few  general  principles. 

The  great  desideratum  is  to  so  form  the  cavity  that  the  visible  ex- 
ternal surface  of  the  filling,  when  placed,  shall  have  a  smaller  diameter 
than  some  portion  which  is  within  the  cavity.  We  should  thus  have 
a  mass  occupying  a  cavity  whose  orifice  would  not  permit  the  passage 
of  its  greatest  diameter.    Such  a  filling  could  not  be  removed  mechan- 


6  METHODS  OF  FILLING   TEETH. 

ically,  except  in  pieces.  If  the  material  therefore  were  durable,  the  fill- 
ing would  be  permanent  as  long  as  the  opening  was  not  enlarged  by 
decay  or  fracture.  There  are,  however,  other  considerations  which 
may  make  it  imprudent,  or  impossible,  to  follow  this  rule,  as,  for  exam- 
ple, when  such  a  course  would  cause  the  excavation  to  approach  the 
pulp  too  nearly.  Dentistry  is  in  many  respects  governed  by  mechan- 
ical laws,  but  when  we  come  to  apply  mechanics  to  living  tissues  there 
are  frequently  points  at  which  the  ordinary  laws  must  be  set  aside  and 
reason  allowed  to  hold  sway.  In  the  case  of  the  retention  of  a  filling, 
reason  would  set  aside  one  law,  however,  only  to  adopt  another,  which, 
though  not  so  general  in  its  significance,  would  be  indicated  in  a  special 
instance.  Where  it  becomes  unwise  to  attempt  to  enlarge  a  cavity  till 
its  orifice  is  its  smallest  diameter,  there  are  usually  at  least  two  direc- 
tions in  which  extension  may  be  made,  which  will  sufficiently  serve  to 
hold  a  solid  filling.  Much  may  be  gained  at  times  by  judicious  rough- 
ening of  the  surface  of  the  cavity.     Fig.  i  exemplifies  such  a  case. 

Fig.  I.  Fig.  2.  Fig.  3.  Fig.  4. 


The  crown  of  a  molar  has  become  denuded  of  enamel,  and  the  dentine 
is  highly  sensitive.  A  few  dovetails  made  with  a  sharp  rose  bur  will 
serve  to  retain  a  filling,  though  the  orifice  has  the  largest  diameter. 
Again,  there  may  arise  cases  where  the  destruction  leaves,  not  a  cavity 
proper  with  an  orifice,  but  merely  a  loss  of  substance  with  no  retentive 
shape  whatever.  It  is  in  these  cases  that  the  ingenuity  of  the  dentist  is 
taxed.  In  many  instances  well-placed  screws  are  of  great  advantage. 
These  will  be  described  later. 

In  the  simpler  forms  of  cavities,  those  which  may  be  described  as 
having  surrounding  walls  and  orifices,  the  rule  first  mentioned  must 
usually  be  applied,  but  judgment  must  be  employed.  These  cavities 
are  of  three  classes,  approximal,  crown,  and  surface,  the  latter  in- 
cluding palatal,  labial,  lingual,  and  festoon  cavities. 

I  shall  consider  approximal  cavities  first,  because  they  are  the 
most  difficult,  and  demand  more  skill  and  judgment.  Fig.  2  is  a 
cross-section  through  an  incisor  which  has  been  filled.  A  casual 
glance  demonstates  the  fact  that  the  filling  could  not  be  dislodged, 
because  the  greatest  diameter,  which  is  in  the  line  a,  <z,  is  larger 
than  the  opening,  b,  b.  The  cavity,  however,  though  mechanically 
correct,   is  made  without  due  consideration  of  the  fact  that  living 


RETENTIVE  SHAPING. 


tissue  is  being  operated  upon.  If  after  the  removal  of  decay  the 
cavity  naturally  assumes  this  shape,  it  is  permissible  to  fill  it  without 
further  alteration  ;  but  whenever  possible,  it  should  be  formed  as  in 
Fig.  3,  which,  while  equally  retentive,  leaves  a  greater  amount  of 
dentine  between  the  gold  and  the  pulp.  This  method  should  be 
adopted  in  all  so-called  "saucer-shaped"  cavities  (Fig.  4),  which  may 
be  deepened  by  grooving  at  a,  a,  the  point  b  being  left  untouched. 

In  Fig.  5  we  observe  a  form,  which,  though  correct  in  its  relation  to 
the  pulp,  and  formed  upon  mechanical  principles,  is  nevertheless  unskill- 
fully  made.  It  would  be  improper  for  one  to  make  such  deep  under- 
cuts intentionally,  and  where  they  have  been  produced  by  caries  the 
orifice  must  be  enlarged  by  chipping  away  the  weak  enamel,  as  indi- 
cated by  the  dotted  lines  a,  a.  Many  fillings  have  failed  through  the 
well-meant  but  unwise  efforts  of  the  operator  to  give  great  retentive 
strength  to  his  cavity  by  deep  undercuts.  Undercutting  to  a  slight 
extent  is  imperative,  but  beyond  that  all  deepening  is  a  source  of  weak- 
ness.    In  placing  gold  in  a  cavity  formed  as  in  Fig.  5,  the  force  used 


Fig.  5. 


Fig.  6. 


—5 


d- 


a  hl£  e 


to  pack  the  gold  into  the  deep  undercuts,  whether  with  hand-pressure 
or  the  mallet,  would  tend  to  strain  the  wall  outward,  probably  result- 
ing in  a  crack,  which,  escaping  the  eye  of  the  dentist,  would  yet  ulti- 
mately result  in  the  loss  of  a  piece  of  enamel  along  the  edge  of  the 
cavity.  This  would  be  more  likely  to  occur  along  the  palatal  border, 
b,  because  the  palatal  undercut  would  be  more  accessible  during 
the  filling-operation.  Thus  an  imperfection  would  be  produced  at  a 
point  out  of  sight,  and  the  patient  would  be  unconscious  of  the  mis- 
hap until  caries  had  supervened.  Then  we  should  hear  our  dentist 
say,  "  My  filling  is  all  right,  but  your  tooth  has  decayed  around  it.'' 
The  deep  undercut  at  the  labial  aspect  c  would  probably  be  not  fully 
filled  because  of  its  inaccessibility,  especially  where  the  separation  was 
but  slight.  Fig.  6  makes  this  plain.  The  gold  does  not  quite  reach 
the  v/all  at  a.  It  has  been  well  proved  that  the  most  expert  dentist 
cannot  fill  a  tooth  with  gold  so  tightly  that  an  aniline  solution  cannot 
stain  the  walls  of  a  cavity.  Therefore  it  is  readily  seen  that  as  soon 
as  the  fluids  of  the  mouth  pass  the  slight  barrier  at  b  and"  reach  such  a 
space  as  that  shown  at  a,  we  have  a  most  favorable  condition  for  the 
recurrence  of  caries  ;  which  explains  the  occurrence  of  the  mysterious 


8  METHODS  OF  FILLING  TEETH. 

bluish  color  which  occasionally  is  seen  around  an  apparently  perfect 
fining.  If  it  is  denied  that  a  filhng  cannot  be  made  water-tight,  it  is 
still  to  be  remembered  that  in  filling  this  labial  undercut,  even  thus 
imperfectly,  the  strain  as  in  the  case  of  the  palatal  aspect  would  prob- 
ably crack  the  thin  enamel.  The  subsequent  loss  of  even  a  tiny 
particle  of  enamel  would  give  sufficient  entrance  for  fluids  into  this 
artificially-produced  lacuna.  If,  in  addition  to  this,  the  excavation  had 
not  been  thorough  and  just  a  little  caries  were  left,  it  would  require 
no  gray-beard  to  explain  the  blueness. 

In  Fig.  7  we  have  an  approximal  surface  occupied  by  a  filling  which 
thus  indicates  the  outlines  of  the  orifice  of  the  cavity.  Fig.  8  is 
placed  in  juxtaposition,  and  lines  are  drawn  through  the  two  for 
comparison.  The  latter  is  a  longitudinal  section  through  the  greatest 
diameter  of  the  filling,  the  approximal  portion  having  been  thus  re- 
moved. By  comparing  the  lines  «,  a  in  the  two  figures,  it  is  seen 
that  the  undercut  toward  the  cutting-edge  is  very  slight.  Any  great 
extension  in  this  direction  is  not  only  unnecessary  but  endangers  the 
corner  of  the  tooth,  already  weakened  by  decay.  Comparing  the 
lines  b,  b,  it  is  seen  that  this  portion  of  the  cavity  is  extended  much 
beyond  the  border.  Also  observe  that  this  extension  takes  the  form 
of  horns,  conforming  in  shape  with  the  imaginary  line  e,  e,  which  rep- 
resents the  gingival  border  of  the  enamel.  By  proceeding  thus  it  is 
plain  that  we  leave  the  enamel  at  the  gingival  border  of  equal  strength, 
whereas  if  with  a  rose  bur  we  cut  a  groove  connecting  the  horns  f,f, 
we  gain  nothing  in  retentive  strength,  while  by  thus  undermining  the 
enamel  unequally  we  leave  it  weak  at^.  In  malleting  gold  against  this 
border  the  greatest  strain  will  be  against  the  weakest  point,  g,  because 
of  unequal  resistance,  probably  producing  a  crack  or  fracture,  which 
readily  explains  in  one  way  the  oft- noticed  recurrence  of  caries  at  the 
gingival  borders.  By  comparing  the  lines  c,  c,  the  labial  borders,  it  is 
seen  that  a  slight  extension,  or  groove,  exists  along  the  full  extent,  de- 
creasing toward  the  cutting- edge.  The  lines  d,  d,  however,  indicate  that 
the  lingual  borders  are  identical,  except  at  h,  where  there  is  a  decided 
dip.  Along  the  lingual  portion  of  an  approximal  cavity  (in  the  six 
anterior  teeth)  it  is  usually  safer  to  make  no  groove  except  at  the 
upper  third,  where  the  thickening  of  the  tooth  gives  sufficient  dentine 
for  a  deep  dip,  which  will  add  great  retentlveness  to  the  cavity.  Fig. 
9  is  important.  It  is  a  section  through  an  Incisor  and  filling,  the 
labial  half  being  removed.  At  a  glance  it  is  seen  that  on  this  plane 
the  cavity  has  no  retentive  shape  whatever.  This  is  because  on  this 
plane,  which  is  through  the  center  of  the  pulp,  extensive  undercutting 
would  either  approach  the  pulp,  or  produce  weak  points  in  enamel. 
The  gingival  border  at  g  is  seen  to  be  strong,  and  shaped  to  resist 
any  necessary  force  which    may  be  brought  against  it.     Were  the 


RETENTIVE  SHAPING. 


cavity  shaped  as  seen  in  Fig.  lo,  we  should  have  g,  a  weak  point,  as 
shown  in  Fig.  8,  where  we  view  the  same  thing  from  another  aspect. 
Extension  toward  the  cutting-edge  as  shown  in  this  figure  would 
make  possible  a  fi"acture  in  the  direction  of  a,  which  would  result  in 
the  loss  of  the  corner. 

Until  I  take  up  special  cavities  in  detail,  it  is  not  necessary  to  say 
more  of  approximal  cavities,  there  being  only  a  few  points  in  con- 
nection with  the  incisor  region  which  do  not  apply  to  bicuspids  and 
molars,  and  vice  versa. 


Fig.  9. 


Fig.  10. 


Fig.  12. 


In  the  preparation  of  what  are  strictly  crown  cavities  there  is  little 
to  be  said  here  beyond  emphasizing  the  necessity  already  pointed  out, 
not  to  leave  too  great  undercuts.  If  the  cavity  be  left  as  in  Fig.  1 1 
after  the  removal  of  decay,  an  attempt  to  insert  gold  would  probably 
result  as  figured,  spaces  occurring  at  a,  a.  Subsequent  mastication 
would  crush  the  weak  enamel,  and  leaky  borders  would  ensue.  Fig. 
12  shows  how  such  a  cavity  should  be  formed,  the  dentine  being  left 
as  thick  as  possible  {a)  over  the  pulp. 


Fig.  13. 


Fig.  14. 


Fig.  15 


The  consideration  of  compound  cavities,  involving  crown  and  approx- 
imal surfaces,  may  be  better  discussed  when  I  come  to  special  cases. 

Festoon  cavities  are  those  which,  of  all  surface  cavities,  require 
most  thought.'  Fig.  13  is  a  section  through  an  incisor  and  filUng. 
Grooves  for  retention  have  been  made  at  points  a,  a,  equidistant 
between  the  central  line  and  the  approximal  surfaces.  These  being 
directed  toward  the  pulp,  or  straight  downward  where  the  pulp  is 
closely  approached,  offer  counterbalancing  resistance  and  are  all- 
sufficient,  especially  because  the  position  is  one  where  there  will  be 
little,  if  any,  mechanical  force  exerted  to  dislodge  the  filling.  In  this 
form  of  cavity  we  obtain  strong  edges,  whereas  if  shaped  as  in  Fig.  14 


lO  METHODS  OF  FILLING  TEETH. 

the  edges  are  weak  {a,  a)  and  liable  to  fracture  during  the  process  of 
filling.  This  would  especially  be  the  case  where  an  approximal 
cavity  either  existed  or  should  afterward  occur.  In  forming  such  an 
undercut  it  is  very  probable  that  the  other  cavity  would  be  reached, 
and  thus  the  enamel  separating  the  two  would  be  very  fragile. 

In  Figs.  15  and  16  we  have  longitudinal  sections,  the  approximal 
surfaces  being  removed.  Fig.  15  shows  a  groove  or  undercut  («) 
toward  the  cutting-edge,  but  none  toward  the  gingiva.  This  latter 
arrangement  furnishes  a  solid  surface  against  which  to  mallet  gold, 
while  the  one  groove,  terminating  in  the  horns  pictured  in  Fig.  13,  is 
all-sufficient  for  retention.  Where  a  second  groove  is  made  toward 
the  gingiva,  as  in  Fig.  16,  the  enamel  or  border  at  a  is  weak,  and 
recurrence  of  decay  more  probable. 

Intentional  Extension  of  Cavities. 

I  n  many  cases  it  becomes  necessary  to  extend  the  limits  of  cavities 
beyond  the  line  of  carious  destruction.  Where  this  extension  is 
internal,  and  is  done  without  enlargement  of  the  orifice  or  cavity- 
border,  the  course  is  pursued  merely  to  obtain  proper  anchorage  for 
the  filling.  There  are,  however,  times  when  the  borders  of  cavities 
must  be  extended,  and  these  cases  we  must  consider. 

It  is  not  uncommon  to  find  a  mouth,  especially  among  children,  where 
the  point  of  a  fine  exploring  instrument  will  readily  detect  a  seemingly 
tiny  cavity  in  the  crown  of  a  bicuspid  or  a  molar.  Suppose  the  pa- 
tient to  be  of  cleanly  habit,  the  mouth  in  a  hygienic  condition,  the 
teeth  free  from  stains,  and  the  caries  unaccompanied  by  discoloration. 
The  operator  selects  a  small  rose  bur,  which  slightly  enlarges  the 
opening  and  then  sinks  into  the  dentine,  throwing  out  a  debris  of 
white  decay  ;  to  be  conscientiously  thorough,  the  case  being  a  bicuspid, 
he  carries  the  bur  along  the  sulcus  to  the  opposite  pit.  The  cavity  is 
then  filled,  fine-pointed  pluggers  and  small  pieces  of  gold  being  used, 
the  whole  when  finished  presenting  a  beautiful  polished  appearance. 
The  crown  is  improved,  since  now  it  is  jeweled  !  Suppose  that  eight 
or  ten  of  such  narrow  streaks  of  gold  be  placed  in  different  teeth 
about  the  mouth.  They  ought  to  last  a  lifetime,  one  would  think. 
Then  why  is  it  that  a  year  later  some  leak,  while  others  show  a  bluish 
discoloration  about  their  borders? 

The  reason  is  that  in  his  endeavor  to  save  tooth-substance  the 
operator  did  not  make  the  cavities  large  enough.  He  did  not  remove 
all  of  the  decay,  and  he  could  not  do  so,  because,  first,  he  did  not  suffi- 
ciently enlarge  the  opening  to  the  carious  region,  and  second,  he  pre- 
pared the  cavities  with  a  bur  alone.  It  is  frequently  impossible  to 
detect  all  the  ramifications  of  decay  with  an  engine-bur,  partly  be- 
cause the  rapid  motion  destroys  the  keen  sense  of  touch,  and  more 


INTENTIONAL  EXTENSION  OF  CA  VI TIES.  1 1 

often  because  the  position  of  the  cavity  is  such  that  the  shank  of  the 
instrument  limits  the  territory  which  can  be  reached,  .  All  cavities 
should  be  scraped  with  spoon  excavators,  and  all  undercuts  explored 
with  a  right-angled  hatchet.  For  this  reason  all  crown  cavities  should 
be  opened  sufificiently  to  permit  the  use  of  hand  instruments. 

Fig.  17  shows  an  extreme  case.  The  patient  presented,  complaining 
that  there  was  a  dull  pain  in  an  indicated  region,  which  she  could  not 
definitely  locate  in  any  special  tooth.  A  second  left  superior  bicuspid 
appearing  discolored,  an  examination  was  made  in  search  of  a  cavity. 
A  fine  explorer  was  passed,  requiring  some  pressure,  into  an  opening 
in  the  anterior  pit  of  the  sulcus.  On  attempting  to  remove  the  instru- 
ment the  entire  crown  came  away,  much  to  the  horror  of  the  patient. 

Close  examination  showed  that  the  only  defect  in  the  enamel  was 
the  small  aperture  through  which  the  explorer  had  been  passed. 
Caries  had  its  starting-point  here,  and  reaching  the  dentine,  the  de- 
vastation continued,  without  further  affecting  the  enamel,  until  the 
pulp  had  been  reached  and  killed.     The  crown  when  cleansed  of  decay 

Fig.  17.  Fig.  18.  Fig.  19.  Fig.  20. 


presented  as  a  complete  hollow  shell  or  cup  of  enamel.  In  Figure  17, , 
which  shows  a  section  through  the  crown,  the  enamel  d  is  seen  to  be 
intact  except  where  the  probe  passed,  a  representing  the  dentine,  all 
of  which  was  carious. 

There  is  a  lesson  to  be  learned  here.  Whenever  caries  reaches  the 
dentine,  whether  through  a  sulcus  in  a  crown  or  through  the  smooth 
enamel  on  an  approximal  surface,  further  extension  of  decay  will  be 
in  the  dentine.  Enlargement  of  the  orifice  is  due  to  the  fact  that  as 
the  enamel  loses  its  support  from  being  undermined,  the  thinned 
borders  chip  or  crumble  off.  This  is  specially  true  of  masticating 
surfaces.  It  follows  therefore  that  all  discoloration  in  the  sulci  is  to 
be  regarded  with  suspicion.  Dark  fissures  should  be  opened  along 
their  whole  extent,  sufficiently  to  allow  proper  examination  with 
a  hatchet  excavator.  If  it  is  found  that  the  enamel  is  undermined, 
the  cavity  can  best  be  further  enlarged  with  a  chisel  and  light  taps  of 
a  mallet,  thus  splitting  off  overhanging  borders  with  the  least  pain, 
and  revealing  the  true  extent  of  the  cavity. 

Fissure-cavities,  however,  are  to  be  opened  even  when  not  dis- 
colored, if  a  cavity  is  found  at  any  part  of  the  sulcus.     It  is  poor 


12  •  METHODS  OF  FILLING   TEETH. 

practice  to  insert  pin-head  fillings  in  such  positions.  It  would  be  safe 
to  say  that  the  sulcus  in  a  bicuspid  should  always  be  opened  to  its  full 
extent,  even  when  caries  appears  in  but  one  pit.  There  may  be  a  few 
cases  which  might  rightfully  be  excepted,  but,  as  stated,  the  rule  is  a 
safe  one.  From  this  dogma  it  follows  that  it  is  improper  ever  to  insert 
two  fillings  in  the  crown  of  a  bicuspid,  one  in  the  pit  at  one  extremity 
of  the  sulcus,  and  one  at  the  other  end.  The  patient  is  thus  made  to 
believe  that  he  receives  two  fillings,  when  truly  but  one  is  needed,  and 
would  serve  better  than  two,  since  the  space  between  is  weak. 

In  considering  molars  we  perhaps  should  be  less  dogmatic,  though 
in  the  inferior  jaw  we  would  still  be  erring  on  the  safe  side,  if  erring 
at  all,  when  we  cut  out  the  crossed  sulci.  I  heard  a  professor  in  a 
dental  college  once,  in  a  lecture,  instruct  his  class  somewhat  differ- 
ently upon  the  point  as  here  stated.  He  said  that  he  had  frequently 
filled  lower  sixth-year  molars,  placing  one  filling  at  each  corner  of 
the  cross,  and  one  in  the  center,  charging  five  dollars  apiece.  Had 
this  gentleman  made  a  single  filling  of  the  whole,  charging  twenty-five 
dollars  for  his  operation,  he  would  have  been  more  scientific,  more 
honest,  and  yet  have  received  the  same  fee.  A  man  may  regulate  his 
fees  as  he  chooses,  but  he  cannot  rightfully  arrange  his  fillings  for 
effect,  at  the  expense  of  durability. 

It  is  necessary  here  to  dilate  a  moment  upon  this  subject  of  enlarg- 
ing the  cavities  in  the  lower  molars,  especially  those  of  the  sixth  year. 
We  are  usually  asked  to  fill  them  in  the  mouths  of  children.  The 
parent  has  no  suspicion  that  there  is  a  cavity  at  all,  and  when  the 
child  returns  home  with  a  tremendous  surface  of  gold  showing,  the 
mother  calls  at  the  next  visit,  charging  perhaps  that  the  dentist  has 
"  bored  a  hole  in  the  tooth."  This  is  the  opportune  time  for  edu- 
cating the  family.  A  candid  explanation  should  be  made,  stating 
that  while  it  would  have  been  possible  to  fill  the  tooth  with  only  a 
small  amount  of  gold,  it  would  surely  have  needed  refilling  in  a  i&<M 
years.  To  those  who  must  have  an  incentive  for  doing  conscientious 
work,  aside  from  the  gratification  of  knowing  that  the  most  skillful 
course  has  been  pursued,  it  may  be  said  that  these  talks  with  parents, 
and  patients  generally,  are  sure  to  redound  to  the  benefit  of  the 
operator. 

The  general  rule  of  cutting  out  the  sulci  of  course. holds  also  with 
the  superior  molars,  but  here  it  is  often  best  to  insert  two  fillings. 
There  is  commonly  found  a  deep  pit  in  the  anterior  portion  of  the 
crown,  a  less  deep  one  existing  posteriorly,  with  a  sulcus  extending 
well  over  into  the  palatal  surface.  Fig.  i8  shows  the  crown  of  a 
superior  molar  properly  filled,  the  anterior  cavity  {a)  being  built  up 
so  as  to  be  free  from  ramification  of  the  sulci,  and  the  posterior 
cavity  {U)  having  been  cut  so  as  to  include  the  palatal  groove.     This 


INTENTIONAL  EXTENSION  OF  CAVITIES. 


13 


latter  direction  should  be  followed  rigidly,  except  where  the  groove 
is  rather  intimated  than  actually  existent.  It  will  sometimes  happen 
that  the  anterior  and  posterior  pits,  instead  of  being  separated  by  a 
ridge,  will  be  slightly  connected  by  a  groove  across  the  ridge.  In  such 
a  case  two  courses  are  open,  dependent  upon  circumstances.  Where 
the  cavities  may  be  made  separately  of  strong  retaining  shape,  they 
should  be  so  formed,  but  in  placing  the  gold  the  filling  may  be  made 
continuous  from  one  cavity  to  the  other  across  the  groove.  This 
accomplishes  the  object  with  the  least  loss  of  substance.  Occasionally, 
however,  the  filling  would  be  better  retained  if  the  two  cavities  were 
united,  in  which  case  the  bur  or  drill  may  be  used.  I  prefer  an 
inverted  cone  bur  here,  thus  forming  at  once  a  slight  but  sufficient 
undercut. 

I  said  that  the  prescribed  rule  cannot  be  as  dogmatically  adhered 
to  in  the  treatment  of  molars  as  in  the  case  of  bicuspids.  This  is 
explained  by  the  assertion  that  not  infrequently  cases  present  where 
it  would  be  useless  to  extend  a  fissure-cavity. 

Fig.  19  shows  a  section  through  a  molar.  Where  the  sulci  occur 
the  enamel  is  seen  to  have  been  formed  separately  over  each  cusp, 
there  being  deep  pits  {a).  This  class  of  fissures  is  frequently  found  in 
the  mouths  of  children.  To  the  eye  there  is  no  sign  of  decay,  and 
there  may  be  none,  but  the  fine  probe  will  be  caught  all  along  the  line  of 
the  fissure,  and  especially  where  two  sulci  cross.  These  imperfections 
{a)  are  not  seen  in  adult  mouths,  because  where  they  exist  cavities 
will  be  formed  before  puberty.  These  fissures  should  be  opened  and 
filled,  regardless  of  the  absence  of  decay,  as  systematically  as  when 
decay  is  present. 

Fig.  19  is  from  a  first  superior  molar,  and  the  natural  pits  {a)  are 
seen  anteriorly  and  posteriorly.  This  imperfection  more  often  occurs 
in  the  inferior  molars. 

In  Fig.  20  we  see  a  section  through  a  superior  molar  which  has 
simply  rounded  grooves  as  sulci  {d)^  and  the  enamel  is  thick  over  the 
dentine  at  all  points.  This  class  of  teeth  is  found  in  either  jaw,  though 
more  commonly  in  the  upper,  and  is  usually  associated  with  a  strong, 
fully-developed  frame.  The  teeth  are  large  and  the  enamel  dense. 
Should  caries  appear  at  one  end  of  a  sulcus,  it  would  be  unwise  to 
extend  the  cavity  as  described.  It  is  more  than  probable  that  decay 
has  supervened  in  consequence  of  some  slight  imperfection  at  the  spe- 
cial point  attacked,  to  fill  which  is  all  that  is  needed. 

To  summarize  as  to  crown  cavities  in  molars  and  bicuspids,  I  would 
advise  as  a  rule  the  placing  of  but  one  filling  in  the  bicuspids  and 
lower  molars,  cutting  out  the  sulci  fully.  In  the  superior  molars  two 
fillings  are  to  be  placed  where  a  marked  ridge  separates  the  anterior 
from  the  posterior  pit.     Where  the  intervening  groove  is  fissured,  the 


H 


METHODS  OF  FILLING   TEETH. 


cavities  are  to  be  united.     This  will  occur  more  frequently  in  the 
second  than  in  the  first  molar,  and  more  often  still  in  the  third  molar. 

I  have  advised  extending  the  crown  cavity  into  the  palatal  groove 
of  the  superior  molar,  but  in  these  cases  the  posterior  fissure  is  usually 
markedly  continuous  with  the  palatal  groove.  With  the  buccal  groove 
it  is  different.  In  the  inferior  jaw  this  groove  often  presents  with  its 
widest  part  toward  the  gum,  narrowing  as  it  approaches  the  crown. 
If  this  groove  is  non-carious,  it  would  usually  be  unwise  to  extend  a 
crown  cavity  into  it ;  if  slightly  carious,  it  is  generally  good  practice 
to  prepare  the  cavity  pear-shaped,  the  apex  toward  the  crown,  and 
not  to  actually  connect  the  crown  cavity  with  it.  Where  caries  is 
extensive  at  both  points,  they  must  be  united,  but  even  then  it  is  best 
to  unite  them  as  little  as  possible,  as  by  deep  undercutting,  the  buccal 
walls  become  very  much  weakened.  Prepare  both  cavities  as  though 
they  were  to  be  filled  separately,  and  then  pass  a  bur  along  from  one  to 
the  other,  making  as  shallow  a  channel  as  is  compatible  with  strength. 

Where  a  crown  cavity  in  a  bicuspid  or  a  molar  is  but  slightly  sepa- 
rated from  an  approximal  cavity,  the  two  should  be  united  and  filled 
as  one.  If  filled  separately,  the  frail  enamel  partition  must  eventually 
be  crushed  out  under  the  force  of  mastication. 

There  is  a  kind  of  extension  which  is  unfortunately  too  often  neces- 
sary. A  patient  presents  to  have  the  teeth  cleansed.  In  removing 
stains  along  the  gum-line  of  a  molar,  the  enamel  is  found  to  have 
become  softened.  Examination  with  a  hatchet  excavator  demonstrates 
that  there  are  two,  or  perhaps  three,  small  cavities  in  close  juxtaposi- 
tion. The  rule  here  is  rigid.  The  cavities  must  be  opeiied  up  and 
formed  into  a  single  groove  ;  moreover,  it  must  be  extended  as  far  as 
the  engine-bur  will  cut  easily.  All  softened  or  softening  material  must 
be  cut  away  until  firm  margins  are  reached.  I  have  known  such  pro- 
cedure to  involve  the  removal  of  nearly  all  of  the  buccal  surface,  and 
once  I  so  formed  a  cavity  completely  encircling  the  tooth  near  the 
neck,  but,  as  I  have  said,  this  is  a  rule  which  must  invariably  be 
enforced.  A  somewhat  similar  condition,  though  from  a  different 
cause  and  different  in  character,  may  arise  from  the  use  of  a  clasp- 
plate.  '  Here  extension  is  indicated  in  another  way.  In  the  first 
instance,  we  aim  simply  to  reach  a  portion  of  tooth-substance  which 
is  strong.  In  the  second,  this  would  not  suffice.  It  will  frequently 
be  found  that  the  caries  exactly  marks  the  part  of  the  tooth  under- 
lying the  clasp,  the  cavity  cleaned  of  decay  showing  just  the  form  of 
the  clasp.  Such  a  cavity  should  be  extended  in  all  directions,  so 
that  when  the  plate  is  again  placed  in  position  the  clasp  will  not  touch 
the  tooth,  but  will  rest  against  the  filHng.  If  this  course  is  not  pur- 
sued, it  is  plain  that  the  width  of  the  clasp  and  of  the  filling  being  the 
same,  the  edge  of  one  lies  just  along  the  border  of  the  other.     As  all 


INTENTIONAL  EXTENSION  OF  CA  VITIES.  \  5 

accumulation  of  food  along  the  edge  of  the  clasp  woujd  of  necessity  be 
just  along  the  margin  of  the  filling,  it  is  easy  to  understand  that 
leakage  would  soon  ensue. 

We  have  now  to  consider  the  anterior  teeth.  In  this  region  a  new 
condition  enters  which  must  often  modify  our  methods.  What  would 
be  good  practice  in  an  inconspicuous  part  of  the  mouth  might  be  very 
reprehensible  in  the  front  of  the  mouth,  because  of  the  resulting  dis- 
figurement. This  exception  to  general  rules  must  be  further  modified 
by  sex,  for  we  might  not  hesitate  to  enlarge  a  cavity  in  the  mouth  of 
a  man  wearing  a  heavy  moustache,  where  we  should  regret  exceed- 
ingly to  place  a  large  gold  filling  in  the  white  teeth  of  a  handsome 
young  miss. 

The  central  incisors  occasionally  are  found  grooved  and  pitted  near 
the  cutting-edge.  Suppose  that  two  or  three  of  these  pits  are  found 
to  be  actually  carious.  Shall  we  unite  them  by  cutting  out  the  groove, 
as  in  the  case  of  a  molar?  Most  assuredly  not,  for  by  so  doing  we 
greatly  disfigure  the  mouth,  besides  materially  weakening  the  end  of 
the  tooth.     This  class  of  decay  is  seen  in  Fig.  21,  and  the  three  cavi- 

FiG.  21.  Fig.  22.  Fig.  23. 


ties  shown  should  be  filled  separately.  The  central  incisors  are  usually 
longer  than  the  laterals,  and  if  this  extra  length  is  sufficient  to  allow 
grinding  off  the  imperfect  end,  thus  removing  entirely  the  pits  and 
groove,  it  should  be  done,  provided  the  centrals  are  not  thereby  made 
shorter  than  the  adjacent  teeth. 

Fig.  22  shows  another  condition.  The  tooth,  originally  perfect, 
has  become  decayed  as  a  result  of  the  presence  of  green-stain. 
When  the  stain  is  removed,  we  find,  let  us  suppose,  three  distinct 
cavities.  The  dotted  line  a  in  the  figure  indicates  the  smallest  cavity 
uniting  the  three  which  could  be  made.  The  result  would  be  a  de- 
plorable disfigurement.  To  unite  the  two  smaller  cavities,  thus  placing 
two  fillings,  would  be  almost  as  bad.  It  will  therefore  be  preferable 
to  fill  the  three  cavities  separately.  Of  several  evils  we  must  choose 
the  least. 

The  six  anterior  teeth  are  sometimes  seen  with  distinct  grooves  in 
their  palatal  surfaces.  This  occurs  most  frequently  in  the  lateral 
incisors,   and  least  often  in  the  cuspids.     Of  course  where  such  a 


1 6  METHODS  OF  FILLING   TEETH. 

groove  is  found  with  caries  at  the  deepest  point,  it  is  essential  to  cut  it 
out  thoroughly.  Sometimes  there  may  be  no  caries  in  the  groove 
itself,  but  an  approximal  cavity  closely  approaches  it.  This  is  shown 
in  Fig.  23,  which  gives  the  palatal  aspect  of  a  lateral  incisor.  The 
palatal  border  of  the  approximal  cavity,  a,  closely  approaches  the  end 
of  the  sulcus,  b.  If  we  fill  the  cavity  without  taking  note  of  the  sulcus, 
it  is  possible  that  no  future  harm  may  supervene.  It  is  more  probable, 
however,  that  caries  would  occur  in  the  groove,  and  burrowing  under 
the  filling  would  loosen  it.  It  might  be  claimed  that  when  this  occurs 
would  be  tTie  time  to  attend  to  the  case,  but  it  must  be  remembered  that 
when  a  tooth  has  been  filled,  the  generally  accepted  idea  of  the  patient 
is  that  it  is  safe  as  long  as  the  filling  remains  in  position.  The  final 
loss  of  a  falling  by  the  burrowing  of  decay  beneath  it  may  be  delayed  for 
an  indefinite  period.  Thus  caries  would  be  progressing  without  being 
suspected  until  a  sudden  pain  gave  warning,  and  by  that  time  the  mis- 
chief would  have  been  done,  the  pulp  being  either  exposed  or  closely 
approached.  It  is  therefore  preferable  to  fill  the  groove  when  treating 
the  approximal  cavity.  The  method  of  procedure  is  slightly  different 
from  that  which  would  be  pursued  for  a  molar.  If  we  unite  the  cavi- 
ties at  the  outset  by  a  fairly  deep  groove,  we  would,  especially  in  a 
lateral  incisor,  produce  a  very  weak  point  at  c,  which  would  be  likely 
to  crumble  under  the  mallet  during  filling.  The  better  plan,  therefore, 
is  to  fill  the  approximal  cavity  first.  This  being  done,  prepare  a 
cavity  along  the  sulcus  decreasingly  deep  as  you  approach  the  ap- 
proximal filling,  just  reaching  that  point  and  no  more,  making  it  as 
shallow  as  would  be  consistent  with  strength. 

The  treatment  of  a  somewhat  similar  condition  upon  the  labial 
surface  must  be  quite  different.  Fig,  24  shows  an  incisor  having  an 
approximal  cavity  {a)  and  a  festoon  cavity  (3),  The  space  {c)  between 
is  necessarily  a  weak  point,  and  would  be  further  weakened  in  pre- 
paring the  two  cavities  for  the  reception  of  separate  fillings.  It  is 
much  better  to  fill  them  as  one  cavity,  cutting  away  entirely  the 
intervening  enamel  and  dentine. 

We  now  come  to  a  most  important  subject,  approximal  cavities. 
Are  we  under  any  circumstances  to  extend  such  cavities  beyond  the 
borders  outlined  by  the  decay  ?  There  are  certain  cases  where  it  is 
imperative,  and  others  where  such  a  course  should  be  prohibited. 

In  the  six  anterior  teeth  the  approximal  cavities  should  be  prepared  as 
small  as  possible,  consiste^it  with  reacJmig  strong  edges.  I  am  aware 
that  this  is  a  dogmatic  assertion  and  at  variance  with  teaching  of  high 
authority.  Nevertheless  my  experience  teaches  me  that  this  course 
cannot  be  too  emphatically  insisted  upon.  Extension  of  approximal 
cavities  in  incisors  has  been  advised,  in  two  directions.  First  toward 
the  gingiva,  to  reach  a  point  anticipatory  of  the  possiole  recession  of 


"SELF-CLEANSING"  SURFACES.  1 7 

the  gum  ;  and  second  around  the  palatal  and  labial  angles,  to  reach 
self-cleansing  lines.  As  to  the  first  proposition,  the  recurrence  of  decay 
toward  the  gingival  borders  of  a  filling,  in  my  opinion,  depends  not 
upon  the  position  which  the  border  occupies,  but  rather  upon  the  form 
given  to  the  border,  the  manner  of  insertion  of  the  filling,  and  very 
largely  upon  the  perfection  of  the  finish.  As  discussion  of  this  must 
occur  at  a  later  point  in  this  work,  no  more  need  be  said  here.  As 
to  the  second  claim,  that  of  reaching  self-cleansing  surfaces,  this  will  be 
as  good  a  place  as  any  for  determining  the  point.  What  is  a  "  self- 
cleansing"  surface  ?  Plainly  the  term  is  a  misnomer.  No  stirface  can 
cleanse  itself.  Manifestly  it  is  meant  to  imply  a  surface  readily  cleansed 
by  the  tongue  or  lips.  The  only  surface  of  the  former  character  is 
the  lingual  aspect  of  the  six  lower  anterior  teeth.  That  the  tip  of  the 
tongue  does  serve  the  purpose  here,  is  amply  proven  by  the  fact  that 
caries  seldom  if  ever  is  seen  in  the  lingual  surface  of  a  lower  incisor, 
the  only  point  on  any  tooth  -where  I  have  never  placed  a  filling.  I  have 
placed  distinctly  lingual  fillings  (not  complicated  with  approximal 
cavities)  in  lower  cuspids,  but  never  in  an  incisor.  This  would  limit 
this  saving,  cleansing  power  of  the  tongue  to  a  single  surface,  of  only 
four  teeth.  Then  when  we  remember  that  this  very  point  is  the  first 
place  we  attack  in  cleansing  a  set  of  teeth,  we  see  what  limited  ability 
as  a  scavenger  must  be  attributed  to  the  tongue.  Next  we  have  the 
lips.  It  is  rare  that  we  observe  a  cavity  in  the  labial  surfaces  of 
incisors  or  cuspids  except  along  the  festoons,  under  green-stain,  or  as 
a  result  of  erosion,  in  which  latter  case  it  is  most  probable  that  the 
lips,  or  the  mucous  follicles  on  their  surfaces,  produce  rather  than 
retard  the  destructive  process.  With  these  exceptions,  we  must  admit 
that  the  lips  may  effect  a  saving  cleanliness.  We  find  that  festoon 
cavities  are  quite  common.  This  indicates  that  the  farther  we  get 
from  that  part  of  the  tooth — viz,  the  cutting-edge — which  can  be 
reached  by  the  edges  of  the  lips,  the  less  cleansing  we  observe.  If 
the  lips  cannot  cleanse  aloiig  the  festoons,  it  is  evident  that  they  cannot, 
and  do  not,  cleanse  around  the  curve  tozvard  the  approximal  surfaces. 
Can  this  be  done  by  the  tongue  ?  It  is  rarely  if  ever  that  one  washes 
the  labial  surfaces  of  the  lower  teeth  with  the  tip  of  the  tongue  ;  and 
as  to  the  upper,  though  this  is  more  common,  the  action  is  to  place 
the  tip  of  the  tongue  about  the  bicuspid  region,  carry  it  along  toward 
the  bicuspids  of  the  opposite  side,  and  then  back.  This  would  wash 
off  the  debris  along  the  labial  surfaces,  but  would  crowd  it  between  the 
approximal  curved  angles,  so  that  if  we  are  to  extend  approximal 
cavities  around  this  angle  to  reach  an  imaginary  cleansing  surface, 
the  extension  should  be  very  great.  Fig.  25  shows  a  section  through 
two  incisors  having  approximal  fillings  as  I  should  advise  them  to  be 
placed,   the  borders  not  having  been  extended  either  lingually  or 


1 8  METHODS  OF  FILLING  TEETH. 

labially.  Fig.  26  shows  a  similar  section,  the  cavities  having  been 
extended  to  what  are  described  as  "  self- cleansing  lines,"  represented 
in  the  figure  by  the  lines  a,  a,  b,  b.  These  lines  indicate  the  surfaces 
touched  by  the  tongue  as  it  is  passed  over  the  teeth.  Observe  that 
the  extension  of  the  cavity-borders  in  the  figure  has  been  carried 
beyond  the  points  of  actual  contact  between  the  tongue  and  tooth 
(^),  for  it  is  plain  that  to  make  a  border  exactly  upon  this  line 
would  be  rather  to  invite  decay  than  to  prevent  it.  A  comparison  of 
these  two  figures  shows  to  what  a  considerable  extent  extension  of 


Fig.  25. 


Fig.  26. 


a~^_ 


2— 


'~~-l 


the  cavity-borders  must  be  carried  to  reach  these  imaginary  ' '  self- 
cleansing'  '  surfaces,  and  I  argue  that  when  we  consider  the  limitations 
of  this  tongue-  and  lip-cleansing,  as  a  tooth-saving  influence,  com- 
pared to  the  manifest  disfigurement  of  the  mouth  by  the  greater 
display  of  filling-material,  the  comparative  infrequency  of  recurrence 
of  decay  along  these  borders  where  gold  has  been  properly  placed, 
and  more  than  all  the  lessened  retentive  power  of  the  cavity,  or 
greater  approach  toward  the  pulp,  it  follows  that  to  extend  an 
approximal  cavity  in  the  six  anterior  teeth  in  any  direction  beyond 


Fig.  27. 


Fig.  28. 


Fig.  29. 


Fig.  30. 


the  amount  required  for  reaching  a  strong  enamel-border  is  extremely 
hazardous  and  unwise. 

Extension  of  approximal  cavities  in  bicuspids  and  molars  is  a  dif- 
ferent subject.  Where  such  a  cavity  occurs  in-  a  bicuspid  or  molar 
distant  from  the  masticating  surface,  it  being  either  impossible  or 
unadvisable  to  obtain  sufficient  separation,  it  is  better  to  extend  the 
cavity  so  as  to  gain  ready  access  than  to  attempt  to  fill  it  with  little 
space.  The  argument  in  these  cases  that  such  extension  must  be 
toward  the  palatal   rather  than  the  buccal  surface,   is   more  often 


FORMA  TION  OF  CA  VITY  B  ORDERS.  1 9 

written  than  is  the  method  practiced.  It  is  preferable  to  extend 
toward  the  buccal  surface,  so  that  the  operator  may  see  his  work. 
Fig.  27  shows  such  a  cavity  in  a  bicuspid,  and  the  dotted  line  indicates 
the  extension  advised. 

Where  the  approximal  surface  is  decayed,  presenting  a  large  saucer- 
shaped  cavity  of  a  form  most  difficult  to  make  retentive  without  en- 
croaching upon  the  pulp  or  producing  weak  surrounding  walls,  it 
is  wise  to  extend  the  cavity  toward  the  crown  and  well  across  that 
surface,  following  the  sulci  and  making  a  deep  pit  at  the  opposite  end. 
Fig.  28  shows  a  section  through  a  tooth  so  prepared,  a  being  the  pit 
depended  upon  to  retain  the  filling. 

A  very  serious  condition  is  occasionally  seen,  which  has  been  pro- 
duced artificially.  Under  the  delusion  of  saving  a  tooth  from  the 
necessity  of  being  filled,  some  dentist  has  filed  a  "V-shaped  self- 
cleansing  (?)  space"  between  two  teeth,  and  then  inserted  a  flat,  or 
flush,  filling  such  as  is  shown  in  Fig.  29.  The  patient  complains 
of  constant  pain  after  meals,  "caused  by  the  impaction  of  food  into 
this  "  self- cleansing"  space,  and  the  removal  of  the  meat-shreds 
with  a  tooth-pick,  the  constant  use  of  which  has  brought  on  a  highly 
congested  state  of  the  gum.  It  is  plain  that  the  only  remedy  is  to 
insert  a  contour  filling.  This  cannot  be  done  in  the  small  cavity 
surrounded  by  thick  flat-faced  walls,  as  figured.  Therefore  the  cavity 
must  be  extended  till  the  walls  are  thinned  at  their  edges,  assuming 
the  shape  shown  in  Fig.  30.  A  properly  contoured  filling  may  then 
be  made  with  the  assurance  that  there  will  be  no  further  complaint  after 
the  gum  has  healed,  which  will  occur  very  soon. 

Formation  of  Cavity  Borders. 

In  considering  the  edge-line  of  cavities,  I  shall  make  a  distinction 
between  the  general  outline  and  the  actual  edge,  nominating  the  one 
"  cavity  border"  and  the  other  "  enamel  margin."  Both  are  subjects 
requiring  discussion  from  different  stand- points. 

As  a  general  principle,  the  cavity  border  must  be  free  from  angles, — 
must  be  curved.  More  than  this,  it  should  be  a  continuous  curve 
rather  than  a  succession  of  curves.  From  an  esthetic  stand-point, 
nothing  is  more  essential  than  that  the  eye  should  rest  upon  a  gently 
curving  line,  rather  than  upon  an  angular  or  scalloped  one.  Many 
operators  in  their  efforts  to  economize  tooth-substance  make  the  mis- 
take of  producing  results  which  are  unsightly.  A  small  filling  with 
an  odd  border  is  more  conspicuous  than  one  which  may  be  larger,  but 
which  has  been  placed  in  a  cavity  correctly  formed.  These  rules,  of 
course,  apply  more  especially  to  such  fillings  as  reach  the  labial  sur- 
faces of  the  anterior  teeth.  They  apply,  however,  to  the  molar 
tesfion  also,  because  in  this  instance  esthetics  and  durability  go  hand 


20  METHODS  OF  FILLING   TEETH. 

in  hand.  To  leave  irregular  borders  in  any  cavity  is  to  produce  weak- 
ness along  the  points  of  contact  between  the  tooth  and  the  filling. 
Chipping  of  the  margin  will  occur  either  during  the  placing  of  the 
filling  or  later. 

Reference  to  a  few  special  cases  will  demonstrate  the  point  more 
fully  and  clearly.  Fig.  31  is  diagrammatic,  but  conveys  the  idea 
clearly  enough.  It  is  supposed  to  represent  the  ragged  outline  of  a 
cavity  in  the  approximal  surface  of  a  central  incisor.  In  Fig.  32  we 
observe  the  same,  prepared  and  filled,  according  to  methods  too  often 
followed.  There  are  three  errors  along  the  border.  The  cavity  has 
been  formed  on  curved  lines,  it  is  true,  but  they  are  weak  lines  and 
not  esthetic.  The  slight  prominence  at  a  has  been  left,  thus  produc- 
ing an  undulating  border,  instead  of  the  more  beautiful  curve  seen  in 
Fig-  33-  Moreover,  if  we  study  the  cleavage  of  enamel  we  discover 
that  this  prominence  is  weak,  since  it  is  unsupported,  and  must  almost 
certainly  crack  during  the  operation  of  filling.  The  force  exerted 
in  packing  gold  against  it  would  probably  produce  fracture  along 

Fig.  31.  Fig.  32.  Fig.  33. 


the  line  of  the  enamel-rods,  and  if  the  disengaged  piece  did  not 
come  away  at  once  it  would  do  so  later,  or  else  decay  would  be  in- 
vited here.  For  similar  reasons  the  sharp  point  at  b  should  not  have 
been  left.  Even  if  no  fracture  were  produced  during  the  packing 
of  gold,  the  loss  of  a  triangular  segment  would  invariably  follow  upon 
use  in  mastication.  Again,  the  heavy  undercut  at  c  is  an  error,  for 
the  strongest  gingival  border  is  one  formed  without  undercut  of  any 
kind,  but  having  a  flat  surface  against  which  force  may  be  freely 
exerted  without  fear  of  chipping.  Fig.  33  is  correctly  formed  and 
decidedly  more  pleasing  to  the  eye.  In  Fig.  34  we  have  another 
cavity,  which  is  too  often  incorrectly  formed,  as  seen  in  Fig.  35. 
This  should  have  a  border  similar  to  Fig.  33.  As  prepared  in  Fig.  35 
the  point  a  is  weak.  Gold  is  a  soft,  malleable  metal,  and  where  it  is 
brought  to  a  thin  edge,  as  seen,  the  impacting  force  of  mastication 
tends  to  flatten  it  out  until  it  curls  and  breaks,  leaving  a  ragged  edge. 
The  point  b  is  weak  for  reasons  already  given. 


FORMATION  OF  CAl'ITY  BORDERS. 


21 


As  I  have  made  my  diagrams  to  deal  with  cavities  involving  the  re- 
storation of  corners,  this  will  be  an  opportune  place  to  discuss  that 
particular  subject.  It  has  been  recommended  by  recognized  authority 
to  form  a  cavity  of  this  character  as  shown  by  the  heavy  shading  in 
Fig.  36.  To  my  mind  this  is  most  unfortunate  teaching.  We  thus 
get  two  sharp  angles,  both  of  which  must  become  weak  points  save  in 
the  hands  of  the  most  skillful,  even  if  this  exception  be  allowable, 
which  is  doubtful.  In  any  event  the  result  is  far  from  beautiful.  Such 
a  cavity  coming  into  my  hands  would  have  been  formed  as  shown  in 
Fig.  33,  for  the  L-like  extension  is  supposed  to  have  been  intention- 
ally made  by  the  operator.  Once  I  was  called  upon  to  refill  a  tooth 
which  had  been  operated  upon  according  to  this  method,  and  in  that 
instance  I  formed  my  cavity  as  indicated  by  the  dotted  line.  Fig.  36, 
approaching  my  ideal  as  nearly  as  possible  under  the  circumstances. 
I  could  have  shaped  it  as  seen  in  Fig.  37,  but  such  a  form  is  so  un- 
common as  to  be  more  conspicuous  than  that  chosen.  In  Fig.  38  we 
see  a  diagram  showing  two  corners  contoured.     In  cases  of  fracture 


Fig.  34. 


Fig.  35. 


Fig.  36. 


Fig.  37. 


from  falling  against  a  curbstone  or  from  other  accident,  the  corner  will 
usually  be  lost,  the  Hne  of  fracture  being  a  straight  one.  A  filling  placed 
without  alteration  of  the  border  would  appear  as  shown  at  a,  and  the 
correct  border  is  seen  at  b.  Let  us  consider  these  two  forms  aside  from 
esthetics.  Suppose  that  the  dotted  lines/,/,  give  the  internal  retentive 
shape  of  the  cavities.  The  force  during  mastication,  which  will  tend 
to  dislodge  the  fillings,  will  come  in  the  direction  indicated  by  the 
dotted  fines  c,  c.  The  border  of  the  corner  a  being  a  straight  line,  it 
is  evident  that  the  retention  of  the  filling,  under  strain,  will  be  entirely 
dependent  upbn  the  strength  of  the  wall  at  d,  of  course  plus  the  re- 
sistance of  the  lower  undercut.  In  the  other  corner  {b)  we  have 
equal  strength,  plus  the  resistance  offered  by  a  well-defined  shoulder 
at  e.  So  that  once  more  we  find  the  curved  line  stronger,  as  well  as 
more  attractive  in  appearance. 

In  cavities  such  as  are  shown  in  Fig.  39,  and  even  where  the  dep- 
redation has  been  less,  it  has  been  advised  to  remove  the  natural 


22  METHODS  OF  FILLING  TEETH. 

corner  as  far  as  the  dotted  line  a,  and  place  a  contour  filling.  The 
argument  is,  that  the  tendency  toward  cleavage  in  both  enamel  and 
dentine  is  so  great  that  this  corner  must  be  lost  sooner  or  later,  so  that 
it  is  best  to  fill  at  once  as  directed. 

This  again  I  think  a  grave  error.  Many  deductions  have  been 
made  as  to  the  cleavage  of  enamel  and  dentine  which  are  misleading, 
because  the  experiments  have  been  conducted  upon  dried  teeth,  out 
of  the  mouth.  Using  the  chisel  upon  these,  the  investigator  finds 
that  very  little  force  need  be  exerted,  either  to  separate  parts  of 
enamel  along  the  line  of  the  enamel-rods,  or  to  cleave  off  slabs  of 
enamel  from  the  underlying  dentine.  In  consequence  of  this  latter 
fact  one  gentleman  has  advised  that  where  the  border  of  decay 
approaches  nearly  the  gingiva,  the  narrow  remainder  of  enamel  should 
be  chipped  away  and  the  gingival  edge  of  the  gold  allowed  to  rest 
against  the  cementum.  It  seems  to  me  that  this  is  going  to  a  great 
and  hazardous  extreme  in  following  a  theory. 

The  truth  is  that  we  do  not  have  to  deal  with  dried  teeth  in  our 
practice.     Therefore  if  we  consider  cleavage  at  all  we  must  study  it  as 

Fig.  38.  Fig.  39. 


we  have  to  contend  with  it.  We  are  called  upon  to  fill  two  classes  of 
teeth, — those  having  living  pulps,  and  those  which  are  partly  devital- 
ized because  of  the  loss  of  that  organ.  A  wholly  dead  tooth,  one  in 
which  both  pulp  and  pericementum  have  died,  should  invariably  be 
extracted. 

In  deciding  as  to  the  form  to  be  given  to  such  a  cavity  as  we  are 
discussing,  it  becomes  important  to  determine  whether  the  pulp  is 
alive  or  dead,  and  if  dead,  whether  it  has  been  freshly  devitalized,  or, 
having  died  from  disease,  the  tooth-substance  has  been  permeated  by 
putrescent  matter. 

Supposing  that  the  pulp  be  alive  and  the  tooth  in  a  state  of  health, 
I  consider  that  it  would  be  malpractice  to  remove  the  natural  corner, 
and  my  advice  is  based  upon  the  result  of  practice  rather  than  upon 
theories,  which,  though  apparently  logical,  often  prove  unpractical. 

The  cavity  borders  should  be  curved  as  gracefully  as  possible  with- 
out making  further  encroachment  upon  the  tooth-substance,  and  the 


FORMA  TION  OF  CA  VITY  BORDERS.  23 

interior  so  arranged  that  the  filling  will  be  retained  from  above,  and 
laterally,  no  dependence  being  placed  upon  the  weak  corner.  A 
slight  bevel  at  <5,  Fig.  39,  will  possibly  serve  as  a  point  of  resistance 
against  such  force  as  would  have  a  tendency  to  crack  the  corner  ;  at 
least  it  is  preferable  to  a  sharp  angle.  At  the  time  of  so  filling  a 
tooth,  it  is  as  well  to  explain  to  the  patient  that  the  corner  is  weak, 
and  may  be  broken  off  in  the  future  ;  that  you  are  obliged  to  choose 
between  taking  it  off  and  risking  future  accident ;  that  you  follow 
the  latter  course  to  give  her  the  benefit  of  the  doubt  and  save  her 
from  the  disfigurement  of  a  larger  filling  as  long  as  possible  ;  and 
finally  that  you  have  so  arranged  your  filling  that  if  the  mishap  should 
occur  you  can  build  on  more  gold,  without  removing  what  you  have 
just  inserted. 

By  this  course  it  is  seen  that  nothing  is  lost,  whereas,  should  the 
fracture  occur,  the  patient  will'  even  then  be  in  no  worse  predicament 
than  that  in  which  her  dentist  would  place  her  by  the  intentional  re- 
Tnoval  of  the  corner;  if  the  fracture  should  not  supervene,  she  would 
certainly  be  the  gainer.  It  may  be  observed  that  I  have  alluded 
to  the  patient  as  ' '  she. ' '  This  is  because  the  force  of  my  argument 
is  greater  when  deahng  with  women,  who  do  not  wear  moustaches, 
and  the  marring  of  whose  beauty  means  more  than  does  that  of  a 
man. 

Thus  it  follows  that  in  healthy  teeth,  whilst  I  recognize  the  element 
of  the  cleavage  of  enamel,  I  have  also  noted  the  remarkable  strength 
which  may  exist  in  an  apparently  weak  spot,  due  to  the  support  of 
healthy  underlying  dentine,  and  the  tenacity  with  which  the  two  co- 
here. 

Where  a  pulp  has  been  freshly  devitalized,  the  tooth  being  other- 
wise healthy,  the  fact  that  the  root-canal  offers  such  excellent  oppor- 
tunity for  anchorage  that  it  would  be  absolutely  certain  that  future 
damage  could  be  repaired  without  removal  of  the  initial  filling,  would 
lead  me  to  follow  the  same  method. 

Where  a  tooth  comes  into  my  hands  in  which  a  pulp  has  been 
long  dead,  the  substance  of  the  tooth  discolored  and  evidently  friable, 
it  then  becomes  a  subject  for  special  consideration.  In  the  diagram  I 
have  shown  the  limit  at  which  I  should  hesitate.  Where  the  decay  had 
proceeded  farther  so  as  to  make  the  corner  weaker  than  here  shown, 
I,  probably,  should  remove  the  corner.  To  determine  whether  to  do 
so  or  not,  place  a  dull  instrument  against  the  corner  and  exert  pres- 
sure. If  cleavage  occurs  under  such  strain,  the  dentist  need  have 
no  doubt  that  he  has  followed  a  proper  course.  A  few  gentle  taps 
with  a  mallet  might  even  be  resorted  to,  and  if  a  crack  should  appear, 
the  corner  should  be  removed. 

There  is  one  other  condition  where  it  is  not  only  advisable  but  im- 


24 


METHODS  OF  FILLING   TEETH. 


perative  to  remove  the  corner.  Having  determined  not  to  do  so,  sup- 
pose that  the  operator  proceeds  to  pack  his  gold.  Reaching  the  weak 
spot,  he  abandons  the  mallet  and  uses  hand-pressure.  In  spite  of  this 
precaution,  a  crack  suddenly  appears  along  the  line  of  cleavage.  The 
corner  should  be  removed  at  once,  whether  the  tooth  be  healthy  or 
otherwise. 

To  emphasize  the  above  arguments,  I  may  state  that  an  examina- 
tion of  my  records  shows  that  I  have  filled  hundreds  of  such  teeth  in 
the  manner  here  advised,  and  that  in  only  two  instances  have  the 
corners  broken  away  afterward.  In  both  cases  the  contour  was  restored 
without  removal  of  the  filling.  I  have  also  a  few  times  repaired 
broken  corners  without  removing  the  original  filling,  where  the  pa- 
tients had  been  in  other  hands  before  coming  to  me. 

■The  economist  of  tooth-substance  frequently  makes  a  mistake  in 
forming  cavities  in  the  approximal  surfaces  of  molars  or  bicuspids. 


Fig.  40. 


Fig.  41. 


Fig.  42. 


Fig.  43. 


Fig.  44. 


In  such  a  cavity  as  is  shown  in  Fig.  40,  he  shapes  the  cavity  as  indi- 
cated by  the  heavy  line.  Operating  between  separated  teeth,  with 
the  little  space  which  we  usually  have,  it  is  plain  that  he  is  at  a  great 
disadvantage  as  soon  as  his  filling  is  half  completed.  He  is  then 
obliged  to  fill  places  which  it  is  almost  impossible  for  him  to  see.  It 
would  be  much  better  to  extend  the  border  to  one .  or  both  of  the 
dotted  lines,  as  might  be  required  to  gain  ready  access  to  the  cavity 
at  all  parts. 

-'•In  the  masticating  surfaces  of  molars  no  special  directions  are 
necessary,  beyond  advising  the  use  of  a  rose-bur  along  the  sulci,  large 
enough  to  allow  the  entrance  of  a  plugger  if  gold  is  to  be  inserted, 
and  larger  still  where  amalgam  is  to  be  used.  It  is  a  mistake  to  cut 
out  sulci  with  small  burs,  and  then  fill  with  amalgam.  The  opening 
all  along  the  line  should  admit  a  small  ball-burnisher,  so  that  in  pack- 
ing the  amalgam  the  mercury  may  be  thoroughly  expressed.  Many 
amalgam  fillings  have  failed  because  of  tiny  burs  having  been  used 
at  the  extremities  of  the  sulci,  so  that  when  placing  the  amalgam  these 
points  were  improperly  filled,  either  with  material  having  an  excess 
of  mercury,  which  on  that  account  has  never  set,  or  with  an  insufiicient 
quantity  dragged  or  wiped  into  the  crevice  with  the  cotton,  spunk,  or 


EXAMEL  JfARGINS.  -S 

bibulous  paper  used  for  smoothing  the  fiUing.  If  a  fair-sized  rose-bur 
is  used,  all  corners  will  be  well  rounded  and  accessible.  It  will  some- 
times happen  that  by  following  two  nearly  parallel  sulci  to  their  ex- 
tremities we  leave  between  a  narrow  strip,  which,  if  left,  is  apt  to 
crumble  under  the  blows  of  the  mallet.  In  such  cases  the  intervening 
bit  should  be  cut  out,  and  the  two  sulci  thus  united. 

In  a  few  rare  instances  the  border  of  a  cavity  may  be  so  placed  that 
a  filling  becomes  a  support  to  a  frail  wall  rather  than  dependent  upon 
it.  A  case  from  practice  will  well  explain  this.  A  patient  once  came 
into  my  hands  having  a  first  bicuspid  which  was  positively  black. 
This  was  before  the  days  of  the  perfection  of  artificial  crowning.  Ex- 
amination showed  the  tooth  to  have  been  filled  with  amalgam.  The 
cavity  Qccupied  a  large  space  directly  through  the  tooth  from  the 
anterior  to  the  posterior  approximal  surface.  Fig.  41  shows  how  the 
dentist  had  formed  the  cavity.  It  will  be  seen  at  a  glance  that  the  fill- 
ing ofifered  no  support  whatever  to  the  weakened  walls.  On  the  con- 
trary, in  mastication,  a  piece  of  food  acting  as  a  w^edge  between  the 
cusps  would  have  a  tendency  to  drive  the  labial  and  palatal  walls  apart 
and  away  from  the  filling.  A  slight  elasticity  of  the  dentine  allowed 
this.  Thus  the  filling  leaked  badly,  and  discoloration  was  largely 
due  to  decay  between  the  amalgam  and  surrounding  dentine.  Great 
care  was  required  to  remove  this  filling,  but  when  accomplished,  and 
all  the  decay  removed,  the  tooth  was  far  from  being  unsightly  in  color. 
I  filled  this  tooth  with  gold,  anchoring  the  filling  in  the  root-canal, 
and  so  shaped  the  borders  that  the  filling  became  a  strong  and  com- 
plete support  to  the  walls.  This  is  shown  in  Fig.  42.  It  is  plain  now 
that  all  mastication  must  be  upon  the  gold.  The  ends  of  the  cusps 
have  been  removed  and  the  upper  extremities  of  the  remaining  walls 
strongly  beveled,  so  that  the  gold  built  over  them  holds  them  firmly 
from  any  tendency  to  bulge  outward. 

Similar  treatment  is  required  in  cases  shown  in  Fig.  43,  where 
abrasion  against  the  lower  teeth  has  worn  away  the  palatal  surface  of 
the  upper  incisors  or  cuspids,  leaving  frequently  a  knife-edge.  This 
incising-edge  should  be  ground  down  to  a  well-marked  bevel  and  gold 
contoured  over  it  as  shown  in  Fig.  44. 

Enamel  Margins. 

A  great  deal  has  been  written  and  preached  upon  this  subject,  and, 
as  in  other  matters,  the  theorist  has  advanced  several  erroneous  prop- 
ositions. The  desideratum  in  all  fillings  is  that  when  polished  the 
line  of  contact  shall  be  as  fine  as  a  hair.  Examination  with  a  jeweler's 
lens  should  not  reveal  any  marked  raggedness.  Considering  the 
arrangement  of  the  margin  from  this  aspect  alone,  there  is  but  one 
method  of  producing  the  result  desired.     The  margin  must  be  smooth, 


26  METHODS  OF  FILLING   TEETH. 

and  at  a  right  angle  to  the  outer  surface  of  the  tooth,  in  all  cavities 
save  those  in  masticating  surfaces.  These  latter  will  be  discussed 
separately. 

In  Fig.  45  we  see  a  section  through  a  central  incisor  and  con- 
toured gold  corner.  The  margin  at  the  labial  surface  <a;  is  a  sharp 
right  angle,  as  is  also  the  margin  on  the  palatal  side.  In  filling  we  of 
course  lap  our  gold  well  over  the  margin,  and  then  trim  away,  seeking 
a  sharp  edge  line.  Any  method  of  polishing  which  scrapes  across  the 
margin  will  deceive  as  to  the  true  edge.  That  is  to  say,  it  is  an 
error  to  use  stones,  polishing  wheels,  or  sand-paper  in  disks  or  strips, 
revolving  the  same  around  the  tooth  from  one  approximal  surface  to 
the  other.  This  method  may  be  employed  at  the  outset  to  remove 
the  excess  of  gold  ;  but  when  it  becomes  necessary  to  polish  away  the 
last  remaining  overlap,  in  order  to  reveal  the  true  margin  and  leave 
a  beautiful  fine  line,  the  polishing  must  be  done  along  the  length  of 
the  margin,  from  the  incisive  edge  toward  the  gum.  If  it  is  an  approx- 
imal cavity  I  prefer  fine  sand-paper  disks,  pliable  enough  to  bend  read- 

FiG.  45.  Fig.  46.  Fig,  47. 

a.  a,  q, 

Gi   C^    C^ 


ily,  though  stiff  enough  to  cut  well.  Revolving  the  disk  rapidly  as 
described,  the  edge  of  the  disk  is  made  to  approach  the  edge  of  the 
gold ;  if  the  latter  is  overlapping  the  margin,  the  disk  attacks  it  in- 
stantly and  removes  sufficient  to  perfect  the  edge,  leaving  gold  and 
tooth-surface  exactly  flush.  The  same  result  may  occasionally  be  ex- 
pected from  the  use  of  a  fine  polishing- stone  (Arkansas  or  Colorado 
stone,  not  corundum),  but  it  must  be  fine  enough  not  to  cut  enamel, 
and  must  cut  gold  very  slowly.  Margins  of  fillings  along  the  palatal 
angle  may  best  be  polished  with  fine  disks,  but  where  the  border 
reaches  the  concaved  surface  small  stones  revolving  from  incisive  edge 
toward  the  gum  best  attain  the  finest  finish.  A  stone  turning  in  this 
direction  will  not  catch  in  the  dam . 

If  approximal  margins  be  beveled  outwardly  (Fig.  46),  as  some 
contend  is  requisite,  it  is  plain  that  we  no  longer  have  a  really  defined 
margin  at  a  or  at  b,  but  simply  an  obtuse  angle  along  a  receding  slope. 
If  this  were  really  an  obtuse  angle,  it  would  be  bad  enough,  but  it  is 
almost  certain  that  the  operator  will  produce  a  rounding  bevel,  so  that 
there  is  really  no  distinct  margin  at  all.  Now  if  gold  be  lapped  over 
this,  how  shall  it  be  polished  so  as  to  obtain  a  strong  edge  to  the  filling 


EXAMEL  MARGINS.  2/ 

and  a  neat,  sharp  marginal  line  ?  The  answer  must  be,  that  it  is  im- 
possible. The  cross-motion  of  a  polishing  instrument  will  not  always 
expose  the  true  edge  even  where  the  margin  is  a  sharp  right  angle,  and 
it  is  less  apt  to  do  so  along  a  bevel.  If  the  disk  or  stone  is  used  as  has 
been  described  to  be  the  best  method  (revolving  along  the  margin),  the 
first  effect  will  be  to  produce  a  scalloped  line,  and  if  the  operator  then 
attempts  to  straighten  out  that  line,  he  removes  the  edge  of  the  gold, 
so  that  a  portion  of  the  beveled  enamel  is  uncovered,  leaving  a  slight 
groove  along  the  length  of  the  tooth  next  to  the  filling.  Fig.  47 
shows  a  section  through  a  tooth  and  filling  after  such  a  mishap,  the 
exposed  bevel  resulting  in  a  groove  showing  at  a. 

This  idea  of  beveling  is  much  more  frequently  advocated  at  the 
gingival  border,  through  a  strange  impression  that  the  margin  which 
has  gold  lapping  over  it  will  better  resist  caries  than  where  the 
gold  is  brought  against  it  in  sharp  contact,  without  overlapping. 
Where  such  a  beveled  gingival  margin  is  polished  with  either  sand- 
paper strips  or  the  approximal  trimmer,  the  groove  described  is  most 
likely  to  occur.  If  the  disk  alone  is  depended  on,  the  overlapping 
gold  will  be  left  with  a  ragged  edge  in  ninety  per  cent,  of  cases.  If 
the  margin  along  the  gingival  border  has  been  formed  with  a  sharply- 
defined  angle,  and  the  enamel  is  supported  internally  by  dentine, 
which  has  not  been  erroneously  cut  away  for  anchorage,  then  gold 
may  be  packed  solidly  against  and  over  it,  and  in  polishing  the  ap- 
proximal trimmer  may  be  freely  used  until  it  no  longer  catches,  when 
a  fine  sand-paper  strip  will  finish  the  marginal  line  as  fine  as  a  hair. 

It  has  been  wisely  argued  that  the  enamel  margin  should  not  assume 
an  acute  angle,  for  the  reason  that  the  enamel  at  the  extreme  edge 
being  unsupported  by  dentine,  will  be  likely  to  crumble  during  the 
operation  of  filling,  because  of  its  tendency  to  cleave.  For  this  rea- 
son it  has  been  advised  that  the  enamel  margin  should  assume  the 
direction  of  the  enamel-rods  at  the  point  operated  upon. 

Thus  theor}'  as  well  as  practice,  and  mechanics,  recommends  that 
the  enamel  margin  should  cut  the  surface  of  the  tooth  at  a  right  angle, 
for  it  is  usually  true  that  the  enamel-rods  are  arranged  perpendicularly 
around  the  dentine,  so  that  they  must  assume  almost  if  not  quite  right 
angles  to  the  surface. 

If  we  examine  the  varying  surfaces  in  the  masticating  portion  of 
a  molar  or  bicuspid,  it  becomes  plain  that  to  follow  the  rule  here  and 
arrange  the  enamel  margin  so  that  at  all  points  it  shall  be  a  right 
angle,  would  be  to  undertake  the  impossible.  Neither  is  it  necessar\% 
for  whereas  in  approximal  and  surface  fillings  we  are  compelled  to 
finish  the  gold  down  flush  with  the  true  margin  of  the  cavity,  in 
molars  and  bicuspids  the  sulci  being  depressions  which  we  wish  to 
eradicate,  as  well  as  to  simply  fill  the  cavity  proper,  we  customarily 


2  8  ME  THODS  OF  FIL  L ING   TEE  TH. 

extend  the  gold  beyond  the  true  cavity-edge,  partly  obliterating  the 
natural  depressions.  If  a  filling  so  placed  is  well  burnished  and 
any  ragged  edges  trimmed  ofif,  the  form  of  the  margin  need  give 
little  concern,  since  it  is  entirely  covered.  Overlapping  in  masticating 
surfaces  is  not  objectionable,  because,  whilst  the  gold  may  spread  out, 
here  as  elsewhere,  it  is  in  such  a  position  that  all  the  force  exerted 
simply  presses  it  more  tightly  against  the  tooth-substance  which  it  is 
intended  to  cover  and  protect. 


CHAPTER   II. 

General  Principles  involved  in  the  Filling  of  Teeth — Methods 
OF  Keeping  Cavities  Dry — ^The  Rubber-Dam — Ligatures — Clamps — 
Leakage — The  Napkin — Chloro-percha — Wedges  vs.  Separators — 
The  Uses  and  Dangers  of  Matrices. 

Methods  of  Keeping  Cavities  Dry. 

During  the  insertion  of  any  kind  of  filling-material,  all  cavities 
should  be  kept  dry  unless  this  is  absolutely  impossible,  which  rarely 
occurs.  It  does  not  follow  from  this  axiom  that  the  rubber-dam  is 
invariably  necessary.  There  are  very  many  occasions  when  a  dexter- 
ous operator  can  dispense  with  the  dam,  which  is  always  annoying  to 
the  patient,  and  yet  insert  as  good  a  filling.  As  a  conspicuous  illus- 
tration of  this,  I  need  but  to  cite  cavities  occurring  in  the  anterior  sulci 
of  superior  sixth-year  molars.  Where  the  patient  is  a  child,  and  the 
cavity  small,  it  is  unwarrantable  to  force  a  clamp  over  a  short  tooth- 
crown,  crowding  painfully  against  sensitive  gum-tissue,  with  the  risk 
of  a  slip  during  the  operation.  This  would  necessitate  the  removal  of 
the  half-finished  filling,  and  beginning  it  anew,  with  the  gum  bleeding, 
thus  adding  to  the  difficulties  of  an  operation  which  could  have  been 
performed  with  little  trouble  by  using  a  napkin.  Another  condition 
where  the  dam  is  sometimes  contraindicated  is  where  the  cavity  in 
an  approximal  surface  extends  below  the  gum  line.  In  order  to  ex- 
pose the  gingival  margin,  various  methods  have  been  advised,  to 
which  I  need  not  allude  at  this  time.  Where  the  depredation  has 
been  quite  extensive,  we  not  infrequently  meet  a  condition  where 
the  gum  about  the  edge  of  the  cavity  is  soft,  yielding  readily  under 
pressure,  but  is  firm  and  unyielding  around  the  rest  of  the  circumfer- 
ence at  the  neck  of  the  tooth.  This  is  especially  true  of  molars.  In 
these  cases,  though  we  may  succeed  in  forcing  the  gum  away  fi-om 
the  gingival  border  of  the  cavity,  we  have  a  condition  similar  to  that 
shown  in  Fig.  48.     Here  it  is  noticeable  that  while  the  cavity  border 


METHODS  OF  KEEPING  CAVITIES  DRY.  29 

is  exposed  throughout,  the  pedicles  of  gum  have  not  yielded  at  the 
buccal  and  labial  angles,  but  retain  a  normal  position.  The  gum  being 
firmly  attached  at  other  points,  it  is  evident  that  if  the  rubber-dam  be 
stretched  over  such  a  tooth,  it  will  in  consequence  of  the  pedicles 

a,  a  span  across,  and  occupy  the  line  b,  b,  so  that  the  cavity  border 
will  be  below  the  dam.  In  many  cases  it  is  not  only  impossible  to 
force  the  dam  down  with  a  ligature  and  keep  it  there,  but  the  effort 
to  do  so,  by  causing  hemorrhage,  compels  the  abandonment  of  the 
operation  at  that  sitting.  Even  where  one  succeeds  in  pressing  the 
rubber  and  ligature  below  the  border,  it  rises  again  when  tied,  because 
becoming  taut  it  must  assume  the  straight  line  b,  b  ;  if  it  is  not  made 
taut,  leakage  will  occur.  To  overcome  this  difficulty,  it  has  been 
suggested  to  use  copper  wire  as  a  ligature. 

In  a  few  mild  cases  this  works  very  well. 
The  wire  ligature  is  applied  about  the  neck 
of  the  tooth,  and  the  ends  twisted  till  tight. 
As  with  the  silk  or  flax,  it  follows  the  line 

b,  b,  but  with  a  suitable  instrument  it  may       ^ — -'-^ 
now  be  forced   below  the  border  of  the 
cavity,  carrying  the  dam  with  it,  and,  being 
metallic,  it  will  retain  its  position.  ' 

Where  this  cannot  be  accomplished,  it  becomes  impossible  to  fill 
the  entire  cavity  with  gold.  Two  courses  are  open, — either  amalgam 
alone  must  be  depended  upon,  or  amalgam  may  be  used  up  to,  and 
slightly  above  the  line  b,  b,  the  rest  of  the  cavity  being  filled  with  gold 
at  a  subsequent  sitting.  In  either  case  a  margin  more  nearly  perfect 
will  be  obtained  if  the  napkin  is  used  instead  of  the  rubber-dam,  the 
gum  being  occasionally  mopped  with  bibulous  paper  or  spunk  during 
the  operation.  This  will  be  more  specially  alluded  to  in  discussing 
the  manipulation  of  amalgams. 

When  it  has  been  decided  to  employ  the  dam,  it  is  requisite  that  it 
should  be  so  placed  that  the  patient  may  suffer  least,  and  the  operator 
have  the  greatest  facility  for  obtaining  access  to  all  pai-ts  of  the  cavity. 
The  first  desideratum  is  that  a  sufficient  number  of  teeth  should  be 
embraced  so  that  all  folds  of  the  rubber  shall  be  well  out  of  the  way. 
There  should  be  at  least  two  teeth  on  each  side  of  the  space  between 
the  teeth  which  are  to  be  filled.  This  as  a  general  rule  will  answer 
in  most  cases.  It  sometimes  happens,  however,  that  much  will  be 
gained  by  embracing  five,  six,  seven,  or  even  more  teeth.  Ca\-ities 
in  the  posterior  surfaces  of  bicuspids  and  molars  are  usually  trying 
cases,  wherein  accessibility  and  good  light  are  essentials  best  obtained 
by  stretching  the  rubber  over  several  teeth.  It  is  usually  sufficient 
to  include  the  central  on  the  side  of  the  mouth  where  the  operation  is 
to  be  performed. 


30  METHODS  OF  FILLING  TEETH. 

All  attempts  thus  far  to  produce  a  rubber  of  light  color  result  in  de- 
stroying its  elasticity  to  such  an  extent  that  the  material  becomes  unfit 
for  dental  purposes.  Thus  we  are  compelled  to  use  a  dark-colored 
dam,  which  has  a  decided  disadvantage  in  that  it  does  not  reflect  light. 
It  therefore  becomes  important  to  economize  the  light  as  much  as  possi- 
ble, by  not  having  any  unnecessary  creases  or  folds.  As  the  jaws  are 
curved,  it  is  plain  that  holes  punched  in  the  dam  in  a  straight  row,  and 
by  guess  as  to  distance  apart,  will  not  permit  the  dam  to  be  stretched 
over  the  teeth  and  lie  smoothly.  To  obtain  the  proper  positions  for 
the  holes  lay  the  dam  over  the  teeth,  stretching  it  so  that  the  incisive 
ends  show  through  ;  then  make  a  mark  with  an  excavator,  which  by 
slightly  scratching  produces  a  whitish  dash  over  each  tooth.  Punch 
the  holes  with  a  sharp  instrument  that  will  cut  clean  round  holes. 
By  this  method  the  dam  may  be  made  to  adapt  itself  without  a  wrinkle. 
The  holes  should  be  graded  in  size  so  that  they  will  tightly  grasp  the 
tooth-neck,  but  they  should  not  be  made  so  small  that  a  tear  may 
occur  at  the  slightest  touch,  or  while  passing  over  a  tooth.  Great 
care  should  be  used  to  have  the  distances  between  the  holes  exactly 
right.  If  too  narrow,  they  stretch  to  span  the  gap,  leaving  a  bit  of 
gum  uncovered  near  the  neck  of  one  of  the  teeth.  If  too  wide, 
especially  at  the  space  where  the  operation  is  to  occur,  trouble  may  be 
found  in  forcing  the  excess  between  teeth  in  close  contact,  or  annoy- 
ance will  occur  from  the  fold  produced  by  it.  Where  teeth  are  close 
together,  a  piece  of  waxed  floss  should  be  passed  between  all  of 
them  before  any  attempt  is  made  to  apply  the  dam.  If  the  floss 
will  not  pass,  neither  will  the  dam.  There  may  be  a  rough  filling,  a 
fracture  of  the  enamel,  a  ragged  edge  of  a  cavity,  or  a  bit  of  tartar, 
either  of  which  will  tear  the  dam .  A  safe-sided  saw  should  be  passed 
between  these  teeth,  and  the  obstruction  removed.  Occasionally 
there  is  adequate  space  near  the  neck,  but,  for  example,  two  incisors 
are  in  such  close  contact  at  their  corners  that  neither  ligature  nor 
rubber  can  be  passed  between  them.  In  such  cases,  drive  a  wedge  of 
wood  at  the  neck  till  the  teeth  slightly  separate,  when  the  dam  may 
be  placed  with  facility  ;  then  remove  the  wedge.  It  is  frequently  ser- 
viceable to  soap  the  dam  about  the  holes. 

It  very  rarely  happens  that  the  dam  can  be  forced  between  the  teeth 
with  a  ligature,  save  perhaps  in  the  bicuspid  region,  where  the  slant- 
ing sides  of  the  cusps  favor  the  method.  The  too  frequent  result  is, 
that  the  ligature  cuts  the  dam,  so  that  while  it  passes  into  the  space 
the  operator  has  to  contend  against  a  disagreeable  leak  afterward. 
Where  such  an  accident  does  occur,  it  is  far  better  at  the  outset  to 
remove  the  dam  and  apply  a  new  piece. 

When  the  cavity  to  be  filled  is  at  the  labial  festoon,  especially  where 
there  has  been  a  recession  of  gum-tissue,  and  caries  has  encroached 


ME  THODS  OF  KEEPING  CA  VI  TIES  Du  i.  31 

upon  the  root,  it  is  necessary  to  make  wider  spaces  than  ordinary 
between  the  hole  in  the  dam  which  is  to  encircle  the  particular  tooth 
and  those  on  either  side  of  it.  If  this  precaution  is  not  taken,  when 
the  clamp  is  used,  and  the  dam  forced  up  above  the  cavity  edge,  the 
rubber  on  each  side  will  have  stretched  so  that  the  gum  between  the 
teeth  will  not  be  covered,  and  an  annoying  leak  will  ensue.  A  little 
practice  easily  teaches  one  how  to  regulate  the  spacing  in  these  cases. 
In  connection  with  festoon  cavities,  the  gum  maybe  forced  back  and 
away  from  the  edge  of  the  cavity  in  either  of  two  ways.  If  it  can  be 
placed  so  that  it  will  have  a  tendency  to  slide  under  the  gum,  a  ring 
cut  from  rubber  tubing  may  be  placed  to  encircle  the  neck,  and  allowed 
to  remain  in  position  for  twenty-four  hours.  In  this  time  it  will  be 
found  to  have  forced  the  gum  slightly  back,  and  also  by  forming  a 
space  between  the  gum  and  tooth  the  free  margin  is  left  less  resistant 
to  pressure  made  by  the  clamp.  Where  the  rubber  ring  would  have 
a  tendency  to  slip  down  toward  the  incisive  edge,  it  cannot  be  used. 
In  these  cases  a  roll  of  cotton  should  be  wrapped  around  the  neck  and 
forced  under  the  gum  as  far  as  possible.  A  ligature  of  flax  thread 
tied  just  below  it  will  hold  it  in  place,  and  in  one  day  the  swelling  of 
the  cotton  will  have  accomplished  the  purpose.  Either  of  these 
methods  is  less  cruel  than  an  attempt  to  force  the  gum  up  by  use  of  a 
clamp. 

Where  a  mouth  is  small,  or  the  lips  non-yielding,  considerable  diffi- 
culty may  be  found  in  placing  the  dam  over  posterior  teeth.  If  the 
operator  has  an  assistant,  his  aid  is  invaluable  in  placing  the  clamp, 
but  in  lieu  of  such  help  the  patient  may  be  made  to  do  service. 
Suppose  that  the  tooth  be  in  the  lower  jaw  ;  the  operator  with  the 
second  finger  of  his  left  hand  can  readily  keep  the  dam  from  sliding 
up  along  the  buccal  side  of  the  tooth.  Momentarily  he  has  the 
second  finger  of  his  right  hand  at  the  lingual  side.  Now  let  him  say 
to  the  patient,  ' '  Pass  the  second  finger  of  your  right  hand  down 
till  you  feel  my  finger-nail,  then  press  against  your  gum,  and  hold 
steadily. ' '  Now  the  operator  may  remove  his  right  hand,  and  is  at 
liberty  to  place  the  clamp.  The  aid  of  the  patient  judiciously  applied 
is  frequently  as  useful  to  the  dentist,  and  more  satisfactory  to  the 
patient,  than  the  help  of  a  third  person.  In  the  upper  jaw,  however, 
the  patient  cannot  assist  so  easily.  He  will  get  his  hand  in  some 
awkward  position,  which  interferes  with  a  clear  view  of  the  work. 
Having  placed  the  dam,  using  both  hands,  the  second  finger  of  the 
left  hand  along  the  buccal  side,  that  hand  may  be  turned  so  that  the 
palm  is  uppermost.  In  this  position,  and  without  moving  the  second 
finger,  the  forefinger  may  be  passed  into  the  mouth  and  made  to  take 
the  place  of  the  finger  of  the  right  hand,  which  has  been  resting 
against  the  palate.     The  dam  is  thus  held  with  the  fingers  of  one 


32  METHODS  OF  FILLING   TEETH. 

hand,  the  tooth  appearing  between.  The  clamp  may  then  be  easily 
adjusted  with  the  other  hand. 

Ligatures. — This  subject  comes  up  naturally  in  the  consideration 
of  the  dam,  but  I  shall  speak  of  it  not  only  in  this  connection,  but 
from  various  other  stand- points.  Indeed,  the  ligature  is  more  valuable 
in  other  work  than  when  used  merely  to  force  the  dam  into  place  and 
hold  it  there. 

To  tie  silk  around  the  neck  of  a  tooth  is  generally  so  painful  that  it 
should  be  resorted  to  as  infrequently  as  possible.  Where  it  must  be 
done,  the  application  of  a  four  per  cent,  solution  of  cocaine,  freshly 
prepared,  will  do  much  to  alleviate  the  suffering. 

Ordinarily  a  ligature  is  not  needed  in  placing  the  dam  ;  certainly 
it  is  a  rare  case  where  more  than  two  teeth  need  tying.  In  placing 
the  dam  over  teeth,  the  edge  of  each  hole  naturally  turns  toward  the 
incisive  edges.  If  left  so,  leakage  will  result.  By  using  a  smooth 
flat  burnisher,  or  other  dull  instrument,  these  edges  may  be  pressed 
upward  toward  the  gum  till  they  become  inverted.  Immediately  the 
contraction  causes  the  edge  to  slide  up  under  the  free  margin  of  the 
gum,  so  that  unless  the  mouth  is  abnormally  supplied  with  saliva  the 
parts  will  be  kept  sufficiently  dry  for  all  practical  purposes.  This  is 
a  general  principle,  which,  once  noted,  will  cause  the  operator  to  use 
ligatures  less  and  less  frequently,  as  he  becomes  more  and  more  dex- 
terous in  inverting  the  edges  of  the  dam  around  the  tooth-neck. 
When,  because  of  the  shape  of  the  tooth  or  the  superabundance  of 
saliva,  this  cannot  be  relied  on,  a  ligature  is  essential.  It  might  seem 
unnecessary  to  tell  how  to  tie  a  ligature,  but  there  are  numerous  in- 
stances where  a  little  more  knowledge  would  benefit  one  who  has  but 
one  way  of  doing  this  seemingly  simple  thing. 

In  the  first  place,  how  can  the  cord  be  tied  tightest?  and  where  is 
the  best  place  to  have  the  knot  ?  It  is  easiest  to  tie  a  tight  ligature 
around  the  central  incisor,  and  the  difficulty  increases  as  the  posterior 
teeth  are  approached.  This  is  presuming  that  the  knot  is  placed 
along  the  labial  or  buccal  festoon.  The  reason  is  that  while  the  hands 
are  free  at  the  median  line,  in  the  bicuspid  or  molar  region  the  cheek 
prevents  tension  in  one  direction.  There  is  a  method,  however,  which 
overcomes  this.  Suppose  that  the  cavity  be  in  the  approximal  sur- 
face of  a  second  bicuspid.  In  placing  the  ligature  around  the  first 
bicuspid,  pass  it  first  between  the  two  bicuspids,  then  around  the  first 
bicuspid  so  that  the  two  ends  protrude  toward  the  buccal  surface. 
Make  a  surgeon's  double  twist,  and  before  drawing  the  knot  tightly  pass 
the  proper  end  between  the  cuspid  and  bicuspid.  The  two  ends  may 
now  be  grasped  and  the  knot  tightened  readily,  because  both  hands 
have  free  play. .  The  knot  thus  occurs  between  the  cuspid  and  bi- 
cuspid.    The  second  tie  is  made  in  the  same  way,  except  that  a  single 


LIGATURES.  -^^ 

twist  is  all  that  is  necessary.  Before  cutting  off  the  ends,  pass  the 
one  on  the  buccal  side  down  between  the  teeth,  so  that  both  protrude 
toward  the  palate.  The  ends,  when  cut  off,  are  out  of  the  way,  and 
cannot  stand  up  in  the  line  of  vision,  as  often  occurs  when  the  knot  is 
made  at  the  labial  festoon.  The  ligature  around  the  second  bicuspid  is 
made  similarly,  the  knot  occurring  between  that  tooth  and  the  molar. 

While  I  advise  placing  the  knot  at  the  approximal  side  of  a  tooth, 
it  should  be  occasionally  along  the  labial  festoon.  We  find  anterior 
teeth,  especially  cuspids  and  lateral  incisors,  so  shaped  at  the  palatal 
festoon  that  it  is  very  difficult  to  keep  the  dam  from  slipping  down. 
If  a  ligature  be  used,  and  pressed  up  around  the  neck  with  an  instru- 
ment, it  is  often  found  as  soon  as  tied  that  it  has  passed  above  the  dam, 
and  nothing  has  been  accomplished.  This  may  be  overcome  by  tying 
a  good  solid  knot  in  the  ligature  first.  When  applied,  this  knot  should 
be  in  line  with  the  palatal  sulcus.  It  gives  a  point  of  resistance  for  the 
instrument  used  to  push  it  under  the  free  margin  of  the  gum,  and 
carries  the  edge  of  the  dam  with  it.  When  using  this  method,  it  is 
best  to  have  the  tying  knot  at  the  labial  festoon,  for  being  opposite 
the  other  it  makes  the  ligature  more  secure.  If  it  be  desirable  to  have 
the  loose  ends  out  of  sight,  they  may  be  carried  between  the  teeth  and 
cut  off  on  the  palatal  side. 

I  now  come  to  a  description  of  ligaturing  which  may  seem  dry 
reading,  because  of  the  difficulty  to  describe  knots  in  words.  To  him 
who  has  heard  that  teeth  may  be  firmly  united  with  flax  threads,  and 
has  doubted  it,  I  say,  take  a  plaster  cast  and  a  piece  of  silk,  then 
follow  my  directions  by  doing  on  the  model  what  I  describe,  and 
the  result  will,  I  am  sure,  repay  the  trouble,  and  the  reading  will  no 
longer  be  unprofitable.  Unless  this  be  done,  even  the  assistance  of 
illustrations  will  not  render  the  description  perfectly  intelligible. 

By  many  it  has  been  claimed  that  we  cannot  fasten  teeth  perma- 
nently with  ligatures.  Certainly  it  cannot  be  done  with  wire,  which 
either  slips  or  breaks,  and  silk  or  flax  it  is  said  will  loosen  after  a  time. 
Again,  the  use  of  thread  of  any  kind  is  considered  uncleanly,  because 
the  brush  will  not  remove  the  debris  which  accumulates  between  the 
ligature  and  the  gum  margin.  This  latter  claim  is  due  to  the  fact  that 
most  men  tie  a  ligature  near  the  neck  of  the  tooth,  if  indeed  it  is  not 
so  placed  as  to  actually  impinge  upon  the  gum.  If  such  a  ligature  be 
worn  for  any  considerable  time,  gingivitis  will  probably  ensue.  I  will 
describe  how  to  tie  together  a  whole  set  of  teeth,  if  there  be  need,  so 
that  they  shall  be  held  firmly,  the  ligatures  being  about  the  tniddle  of 
the  teeth  instead  of  at  the  necks.  Before  doing  so,  I  wish  to.  touch  on 
the  use  of  ligatures  in  connection  with  the  filling  of  teeth  which  are 
either  loose  or  sore  from  wedging. 

I  shall  first  consider  the  last  specified  condition.     Two  teeth  having 

3 


34  METHODS  OF  FILLING   TEETH, 

been  spread  apart  by  wedging,  are  slightly  loose,  and  sore  to  pressure. 
Because  of  some  necessity,  let  us  suppose  that  it  is  impossible  to  defer 
the  operation.  The  teeth  must  be  filled  at  once,  yet  the  hand-press- 
ure, or  mallet,  used  for  condensing  the  gold  causes  excruciating 
pain.  Proceed  as  follows  :  Imagine  that  the  cavities  are  at  the  me- 
dian line,  in  the  anterior  approximal  surfaces  of  the  central  incisors. 
The  dam  is  made  to  include  six  teeth.  A  stout  flax  thread  is  waxed 
and  passed  between  the  lateral  incisor  and  the  cuspid  on  one  side.  A 
surgeon's  double  knot  is  made  so  that  it  occurs  between  the  lateral  and 
central  incisors.  This  being  firm,  the  two  ends  are  passed  around  the 
central  incisor,  and  the  double  twist  drawn  tightly  along  the  anterior 
approximal  surface  ;  the  central  is  thus  drawn  tightly  against  the  lateral. 
The  knot  being  completed,  the  two  ends  are  next  carried  back  and 
tied  along  the  posterior  surface  of  either  the  lateral  or  the  cuspid, 
should  the  lateral  not  be  firm  enough  to  give  good  support.  The 
same  proceeding  on  the  other  side  of  the  mouth  produces  the  result 
that  both  central  incisors  are  bound  firmly  to  their  neighbors.  To 
complete  the  stability  a  wooden  wedge  must  be  forced  between  the 
incisors,  giving  all  the  space  possible,  and  acting  as  a  keystone  to  the 
arch.  Teeth  thus  held  may  be  filled  with  gold  when  otherwise  they 
could  not  be  touched. 

When  from  pyorrhea  or  other  causes  a  single  tooth  is  found  to  be 
quite  loose,  it  is  frequently  advisable  to  unite  it  to  its  neighbor  with  a 
gold  filling.  It  has  been  advised  to  apply  the  dam  and  then  encase 
the  teeth  with  oxyphosphate  of  zinc  (some  use  plaster  of  Paris). 
This  is  sometimes  best,  especially  with  the  anterior  lower  teeth. 
Where  the  tooth  is  either  a  molar  or  a  bicuspid,  I  have  usually  been 
able  to  obtain  satisfactory  stability  by  the  use  of  ligatures.  In  Fig. 
49  are  shown  a  first  and  second  molar,  with  a  continuous  groove  from 
one  to  the  other,  and  ligatures  binding  the  two  together.  Only  two 
rows  of  ligatures  show,  and  these  would  be  insufficient ;  but  I  have 
allowed  the  artist  to  draw  but  two,  lest  the  figure  be  confusing.  The 
dam  being  in  position,  the  waxed  flax  is  passed  between  the  first 
molar  and  the  bicuspid,  and  a  double  knot  made  between  the  molars, 
in  the  manner  already  described.  Then  the  ends  are  carried  back 
around  the  second  molar  and  tightly  tied  along  the  posterior  surface, 
the  loose  tooth,  whichever  it  be,  being  thus  drawn  tightly  against  the 
firmer  one.  This  is  what  I  term  the  figure  8  ligature,  and  is  to  be 
followed  by  the  figure  O,  which  is  accomplished  by  bringing  the  ends 
around  and  tying  them  along  the  anterior  surface  of  the  first  molar, 
Fig.  49  a.  Thus  the  two  teeth  are  brought  toward  each  other  by  different 
ways.  In  Fig.  49  the  figure  8  ligature  is  seen  nearest  to  the  gum,  and 
passing  between  the  teeth,  while  the  figure  o  is  the  higher  one,  seen 
to  span  the  space.     As  has  been  already  said,  these  two  alone  are  not 


LIGA  TURES. 


35 


sufficient  for  the  purpose,  but  a  further  stability  is  attained  by  repeat- 
ing the  process.  If  possible,  the  thread  should  be  cut  off  at  the  outset 
long  enough  to  serve  for  all  the  tying.  If  this  be  done,  the  next  step 
would  be  to  work  backward  once  more,  using  the  figure  8,  and  then 
forward  again  with  the  other.  If  the  teeth  are  thus  enwrapped  six  or 
eight  times  (that  is,  three  or  four  of  each),  the  loose  tooth  will  not  only 
be  firmly  held  against  the  other,  but  will  be  supported  so  that  the 
mallet  does  not  cause  pain. 

Fig.  49. 


If  the  ligatures  are  well  and  neatly  placed,  one  will  lie  above  the 
other  so  that  when  completed  they  resemble  tape. 

I  now  come  to  the  ligaturing  of  four  or  more  teeth,  whether  for  a 
temporary  or  permanent  purpose.  I  may  as  well,  perhaps,  enumer- 
ate some  of  the  circumstances  wherein  such  tying  becomes  useful. 
Where  teeth  are  badly  loosened  by  pyorrhea,  so  that  cure  is  either 
impossible  or  else  must  result  only  after  a  course  of  treatment  cover- 
ing a  year  or  more,  if  they  are  to  be  united,  it  will  probably  be  best 


Fig.  49  a. 


to  accomplish  this  by  continuous  gold  filling  or  some  method  other 
than  resorting  to  ligating.  Where  the  disease  is  in  an  incipient  stage, 
or  where  the  teeth  are  in  a  mouth  which  it  would  be  wrong  to  disfigure 
by  a  show  of  gold,  then  the  ligature  must  be  depended  upon.  Again, 
the  flax  thread  may  be  relied  upon  in  cases  of  teeth  loosened  by  frac- 
ture ;  for  holding  regulated  teeth  during  twenty-four  hours  while  a 
retaining  plate  is  being  made  ;  for  the  support  of  one  or  more  loosened 
teeth,  elongated  so  that  •shortening  by  file  or  corundum  wheel  is  neces- 


^6 


METHODS  OF  FILLING  TEETH. 


sary  ;  or  for  any  purpose  whatsoever  where  it  is  desired  to  hold  for  a 
period  not  exceeding  six  months,  a  number  of  teeth  in  a  fixed  position. 

Let  us  imagine  a  case  such  as  I  was  recently  called  upon  to  treat. 
A  portly  gentleman  fell  against  a  curb  while  crossing  a  street,  and, 
striking  against  his  upper  lip,  loosened  the  six  anterior  teeth,  breaking 
the  corners  from  one  or  two  and  chipping  the  others.  Whether  he 
calls  immediately  after  the  accident,  or  foolishly  waits  three  weeks 
(as  my  patient  did),  until  inflammation  has  set  in  and  one  or  two 
fistulee  have  appeared,  the  first  thing  to  be  done  is  to  make  the  teeth 
firm.  In  the  instance  cited,  I  accomplished  this  with  flax  so  well  that 
not  only  were  the  teeth  made  so  firm  that  mastication  became  at  once 
possible,  and  under  treatment  all  were  saved,  but  I  was  enabled  to  grind 
the  jagged  edges  from  the  teeth  without  discomfort,  although  before 
the  tying  it  was  painful  for  him  to  touch  the  teeth  with  his  tongue. 

By  the  aid  of  Fig.  50  I  will  endeavor  to  show  how  this  may  be 
accomplished.     In  the  figure  are  seen  two  rows  of  ligatures.     The 

Fig.  50. 


upper,  or  one  nearest  to  the  gum  margin,  is  simply  an  extension  of 
the  figure  8  ligature,  so  that,  as  seen,  it  includes  six  teeth.  One  point 
must  be  mentioned  in  this  connection.  As  already  described,  the 
double  twist  is  made  between  the  teeth  and  drawn  tightly,  one  end  of 
the  thread  being  toward  the  palate  and  the  other  toward  the  lips. 
In  the  posterior  teeth  I  have  directed  that  the  second  half  of  the  knot 
should  be  similarly  made.  In  the  incisor  region  the  knot  must  be 
completed  with  both  ends  presenting  at  the  labial  aspect.  By  follow- 
ing this  advice,  the  action  of  drawing  the  teeth  together  is  attained 
while  tightening  the  double  twist  between  the  teeth,  but  were  the 
knot  completed  in  the  same  manner  it  would  make  a  bulge  at  that 
point  which  would  prevent  close  contact  when  the  next  tooth  was  in- 
cluded. By  having  both  ends  at  the  labial  aspect,  the  bulge  of  the 
knot  occurs  at  the  labial  angle,  where  it  cannot  interfere.  Thus  the 
knot  does  not  show  in  Fig.  49,  while  in  Fig.  50  one  is  seen  at  every 
space.  In  the  figure  it  may  be  observed  that  the  ligature  starting  at 
the  cuspid  has  been  carried  along,  tying  each  tooth,  till  it  finishes 


LIGATURES.  '  37 

at  the  opposite  cuspid,  where  the  ends  are  seen.  Once  more  I  have 
left  the  work  incomplete,  lest  the  illustration  should  be  confusing.  In 
practice  I  should  after  reaching  this  second  cuspid  reverse  the  order 
of  work  and  proceed  backward  again,  tying  in  each  tooth,  till  I  ended 
where  I  had  begun. 

In  Fig.  50  is  seen  a  row  of  ligatures  nearer  the  cutting-edges  of  the 
teeth.  These  are  applied  in  a  different  manner,  and  this  method  I 
term  "weaving."  If  the  reader  will  consult  Fig.  50  «,  or  else  operate 
on  a  model  as  before  suggested,  this  most  valuable  method  will  be 
made  clear.  In  this  case  the  tying  is  begun  around  the  right  cuspid, 
the  knot  being  made  at  the  center  of  the  labial  surface.  There  are 
now  two  loose  ends.  One  is  carried  inward,  passing  between  the 
cuspid  and  the  lateral  incisor,  then  outward  between  the  lateral  and 
central  incisors.  The  other  end  is  carried  straight  across  the  space, 
passed  inward  between  the  lateral  and  central  incisors,  and  then  out- 

FiG.  50  a. 


ward  between  the  lateral  incisor  and  the  cuspid.  Then  the  ends  are 
tied  once  more  into  a  knot,  this  time  at  the  center  of  the  labial  surface 
of  the  lateral  incisor.  In  a  similar  way  the  ' '  weaving ' '  is  continued 
till  the  opposite  cuspid  is  reached,  when  the  ends  are  cut  off  short,  no 
effort  being  made  to  return.  In  some  instances  I  use  both  these 
methods  on  the  same  set  of  teeth,  as,  for  example,  in  cases  of  frac- 
ture, but  I  must  call  attention  to  the  fact  that  they  are  totally  differ- 
ent in  their  action.  The  figure  8  simply  draws  the  teeth  together 
laterally,  while  the  "weaving"  will  force  outward  any  tooth  which 
stands  within  the  arch.  This  in  many  cases  is  desirable,  while  in 
others  it  is  to  be  avoided.  Where  the  four  inferior  incisors  are  loose, 
and  the  cuspids  either  absent  or  of  such  form  that  a  ligature  cannot 
be  tied  securely,  if  the  weaving  method  were  used  about  the  four  teeth 
the  result  would  be  that  they  would  stand  in  a  straight  line,  which 
would  be  mischievous.  In  such  a  case  the  arch  must  be  braced  with 
the  figure  8  ligature  first.  If  the  cuspids  cannot  be  utilized,  then  begin 
around  a  bicuspid  and  skip  around  the  cuspid.  On  the  other  hand,  it 
sometimes  occurs  that,  though  all  the  teeth  are  loose,  one  is  much 


38 


METHODS  OF  FILLING  TEETH. 


more  so  and  stands  within  the  arch.  Here  the  weaving  alone  will 
usually  not  only  be  sufficient,  but  will  force  the  irregular  tooth  into 
proper  position. 

It  is  noticed  that  in  the  figure  both  rows  of  ligatures  are  well  away 
from  the  gum  line.  To  accomplish  this  the  dam  must  be  placed,  and 
just  before  tying  in  each  tooth  the  labial  and  lingual  surfaces  should 
be  smeared  lightly  with  sandarac  varnish. 

It  may  sometimes  occur,  however,  that  ligatures  tied  in  this  way 
may,  in  spite  of  the  precaution  advised,  have  a  tendency  to  slide 
upward  toward  the  gum.  This  would  occur  when  the  teeth  are  very 
much  constricted  at  their  necks,  and  especially  when  there  is  a  copious 
flow  of  saliva.  Such  slipping  would  not  only  overcome  the  object  of 
the  operator,  the  ligatures  becoming  loosened  and  no  longer  binding 
the  teeth  rigidly  in  the  desired  position,  but  would  actually  do  dam- 
age by  impinging  upon  the  gum.  This  would  especially  be  true  in 
pyorrhea  cases,  when  the  gums  must  be  kept  absolutely  free  from 

Fig.  50  b. 


irritation  during  treatment,  this  being  quite  as  essential  as  the  fixation 
of  the  teeth 

If  it  be  found  that  the  ligature  is  likely  to  slip,  a  fourth  precaution 
is  necessary.  The  procedure  is  as  follows  :  The  teeth  having  been 
tied,  a  linen  thread — No.  20 — is  waxed  and  one  end  passed  between 
the  ligature  and  the  tooth  at  the  labial  aspect;  then  over  the  incisive 
edge,  and  up  between  the  ligature  and  the  tooth  at  the  palatal  aspect; 
then  down  and  over  the  incisive  edge  again,  when  the  two  ends  are 
tied,  the  knot  occurring  over  the  knot  of  the  original  ligature.  The 
result  is  shown  in  Fig.  50  b. 

In  the  illustration  the  ends  are  left  somewhat  long,  to  indicate  the 
tying,  but  in  practice  they  would  be  cut  shorter.  In  tying  bicuspids 
in  this  manner,  the  thread  would  cross  between  the  cusps  and  rest  in 
the  sulci. 

There  is  another  method  of  securing  ligatures  against  slipping, 
which  may  be  used  when  the  occlusion  is  such  that  the  guard  threads 
passing  over  the  incisive  edges  would  be  cut  in  mastication ;  it  is  a 


CLAMPS.  39 

method  also  peculiarly  useful  in  regulating  cases,  as  it  can  be  utilized 
in  connection  with  rubber  ligatures,  which  would  not  be  held  with 
the  guard  threads.  In  this  second  method  a  narrow  strip  is  cut  from 
pure  gold  plate,  about  30  gauge.  This  is  made  long  enough  so  that 
when  bent  into  the  shape  of  the  letter  U,  each  end  may  be  passed  up 
between  the  ligature  and  the  tooth,  one  end  on  the  labial  and  one  on 
the  palatal  side.  This  done  it  is  pressed  up  tightly,  and  then  each 
end  is  turned  down  over  the  ligature,  and  the  whole  made  to  conform 
to  the  shape  of  the  tooth  by  pressure  with  the  thumb  and  finger,  the 
soft  metal  yielding  nicely.     A  guard  of  this  kind  will  not  slip. 

Clamps. — The  usefulness  of  a  clamp  largely  depends  upon  its  grip 
upon  the  tooth  to  which  it  may  be  applied,  and  this  in  turn  is  pro- 
portionate to  its  adaptation  and  to  its  spring  force.  When  not  in  use 
the  jaws  should  approach  each  other  so. nearly  that  the  distance  be- 
tween them  is  about  one-half  of  the  diameter  of  the  tooth  which  it  is 
intended  to  encircle,  and  the  spring  should  be  so  strong  that  when 
stretched  over  such  a  tooth  it  will  bind  it  firmly.     A  clamp  for  a  bi- 

FiG.  51.  Fig.  52.  Fig.  53. 


27  26  60 

cuspid  should  have  a  spring  so  powerful  that  one  could  not  endure 
the  pressure  were  it  placed  upon  the  little  finger,  and  one  for  a 
molar  should  cause  discomfort  if  similarly  placed.  This  is  a  fair  test, 
and  all  which  do  not  so  pinch  the  finger  would  prove  worthless  in 
general  practice. 

If  the  practitioner  can  afford  it,  he  should  supply  himself  with  a 
set  of  Delos  Palmer  clamps,  because  these  are  more  accurate  in  their 
adaptation  than  any  others  which  have  been  devised.  Where  the 
dentist  is  compelled  to  economize,  he  will  be  able  to  get  along  com- 
fortably with  just  three  clamps,  excluding  cervix  clamps.  These  are 
bicuspid  clamp  No.  27,  and  molar  clamps  Nos.  26  and  60.  Of  these 
latter,  No.  60  is  adaptable  to  more  cases  than  any  one  clamp  that  I 
have  ever  used,  but  it  will  sometimes  occur  that  a  longer  arm  to  the 
bow  would  give  a  better  view  of  the  cavity,  by  stretching  the  rubber 
backward.     Then  No.  26  is  preferable. 

A  clamp  is  not  needed  with  any  of  the  incisors  or  cuspids"  as  a  rule, 
except  for'cavities  occurring  along  the  labial  festoon.  For  this  posi- 
tion the  ideal  clamp,  which  will  be  universal  in  its  application,  is  still 
to  be  invented      There  are  two,  however,  which,  within  their  limita- 


40  METHODS  OF  FILLING   TEETH. 

tions,  are  most  useful.  One  is  Dr.  W.  W.  Evans's  form,  Nos.  74  and 
75.  These  are  made  either  with  or  without  a  set  screw.  I  beHeve 
that  this  screw  has  been  practically  useless  to  the  majority  of  dentists, 
and  yet  it  is  really  invaluable.  The  inventor  says  of  it,  ' '  The  offiice 
of  the  screw  is  to  tighten  the  hold  in  cases  where  the  clamp  does  not 
fit  securely."  While  this  may  have  been  the  object  aimed  at,  it  is  a 
purpose  not  served  for  several  reasons.  In  the  first  place,  it  not  in- 
frequently happens  that  the  clamp  is  not  pressed  up  sufficiently  far  to 
allow  the  screw  to  reach  the  tooth  at  all.  Secondly,  when  it  does 
touch  the  tooth  it  rests  upon  a  sloping  surface,  so  that  if  it  is  screwed 
down  it  displaces  the  clamp.  Again,  were  it  to  reach  a  perfectly  flat 
plane,  at  the  very  best  part  of  the  tooth  for  its  action,  a  moment's 
thought  will  show  that  to  screw  it  down  would  have  a  tendency  to  lift 
the  jaws  up  from  the  tooth,  and  so  loosen  the  clamp.  Therefore  as  a 
screw  it  is  useless,  but  as  a  projection  above  the  surface  it  is  most 
valuable.     Supposing  the  tooth  to  be  fi.lled  is  a  cuspid,  the  procedure 

Fig.  55. 


Fig.  54. 


would  be  to  apply  the  dam  over  several  teeth,  and  then  tie  ligatures 
about  the  necks  of  the  lateral  incisor  and  the  bicuspid,  leaving  long 
ends.  Next  press  the  clamp  high  up  on  the  tooth,  and,  holding  it 
firmly,  make  a  knot  with  the  loose  ends  of  the  ligatures  from  both 
teeth,  around  the  projecting  head  of  the  screw,  so  that  when  drawn 
tightly  it  tends  to  force  the  clamp  upward.  Completing  the  knot 
makes  the  clamp  secure,  and  the  operation  may  be  finished  without 
fear  of  slipping.  Of  course,  for  this  purpose,  a  small  hook  would 
answer  in  place  of  the  screw-head,  but  we  may  utilize  the  clamp  as  it 
is  furnished  to  us.  Therefore  the  form  with  the  screw  is  preferable  to 
that  which  is  without  it. 

The  peculiar  shape  of  this  clamp  makes  it  specially  useful  in  cus- 
pids, the  bulbous  portion  of  the  tooth  at  the  palatal  side  near  the 
gum  offering  an  excellent  point  of  resistance  to  the  concaved  jaw, 
while  the  two  narrow  projections  above  admirably  fit  about  the  labial 
surface  and  offer  good  view  of  the  work.  At  the  same  time  the  clamp 
is  limited  in  its  usefulness  by  the  fact  that  these  projecting  jaws  fre- 


LEAKAGE. 


41 


quently  hide  a  portion  of  the  cavity  should  it  encroach  upon  the 
approximal  surface.  In  favorable  cases  I  have  filled  the  portion  along 
the  festoon,  and  then  have  removed  the  clamp  'in  order  to  reach  that 
part  which  it  covered.  It  is  an  exception,  however,  when  this  can 
be  done  without  the  ingress  of  moisture.  Another  class  of  cavities 
where  this  clamp  cannot  be  employed  is  where  there  has  been  extreme 
recession  of  the  gum  about  the  neck  of  a  long  cuspid,  followed  by 
caries  which  reaches  the  receded  gum-margin.  The  bow  limits  the 
distance  to  which  the  clamp  may  be  made  to  reach. 

For  teeth  other  than  the  cuspids  the  How  cervix  clamp.  No.  125,  is 
the  best,  known  to  me.  The  inventor  has  recognized  the  fact  that  a 
clamp  for  these  cases  should  have  three  bearings  upon  the  tooth,  be- 
cause of  the  fact  that  the  palatal  jaw  will  not  bite  on  a  line  with  the 
labial.  Being  bowed  over  the  cutting-edge  of  the  tooth,  it  has  the 
same  limitation  as  the  Evans. 

I  will  dismiss  the  subjectof  clamps  by  saying  that,  excepting  festoon 
cavities,  the  clamp  should  preferably  be  placed  upon  a  tooth  other 
than  the  one  to  be  filled  ;  also,  in  applying  a  clamp  care  should  be 
taken  not  to  press  too  hard  against  the  sensitive  gum,  and  especially 
not  to  bite  the  gum  itself,  as  is  often  done  on  the  palatal  side. 

Leakage. — When  we  recall  that  the  dam  is  placed  over  teeth  for 
the  purpose  of  keeping  out  moisture,  it  is  plain  that  when  leakage 
occurs  our  object  has  been  frustrated  either  wholly  or  in  part.  Much 
has  been  written  to  account  for  the  failure  of  gold  fillings  along  the 
gingival  border.  I  think  ninety  per  cent,  of  these  failures  may  be 
attributed  to  leakage  during  the  operation.  Moisture  is  easily  dammed 
up  in  a  dry  mouth,  but  in  one  abundantly  supplied  with  saliva  the 
greatest  skill  is  required  to  keep  a  cavity  absolutely  dry, — so  dry  that 
.  at  no  time  after  placing  the  dam  can  even  a  trace  of  moisture  be 
observed. 

It  will  profit  us  to  consider  somewhat  carefully  this  subject  of  leak- 
age, especially  in  relation  to  failure  at  the  gingival  margin. 

Let  us  suppose  that  the  cavity  is  in  the  approximal  surface  of  a 
central  incisor,  and  so  closely  approaches  the  gum  that  a  ligature  is 
needed  to  bring  the  gingival  border  into  view.  Before  placing  the 
dam  the  parts  are  all  wet ;  so  after  the  dam  has  been  placed  this  moist- 
ure must  be  wiped  away,  and  this  is  done.  The  dentist  then  proceeds 
to  prepare  the  cavity,  when,  after  using  a  chip-blower,  he  is  surprised 
to  find  that  some  of  the. dust  still  adheres  near  the  upper  border. 
This  shows  that  there  was  moisture.  He  concludes  that  he  had  not 
wiped  it  thoroughly  dry,  and  does  so  now.  He  uses  the  engine-bur 
a  second  time,  and  when  the  dust  has  been  blown  away  there  is  still 
the  same  evidence  of  moisture.  Having  thoroughly  dried  the  part 
before,  he  is  now  satisfied  that  there  is  a  leak.     Examination  shows 


42  METHODS  OF  FILLING   TEETH. 

none,  or  rather  none  that  is  discernible  to  the  eye.  Therefore ,  as  he  can 
find  no  leak,  he  is  satisfied  that  there  is  none.  To  be  quite  sure, 
however,  the  cavity  n'ow  being  ready,  he  uses  the  warm-air  syringe, 
and  proceeds  with  his  filling,  placing  a  handsome  piece  of  work,  beauti- 
fully polished.  In  a  couple  of  years  he  finds  this  with  decay  about 
the  gingival  border,  and  perhaps  writes  a  learned  essay  upon  the 
instability  of  fillings  at  this  point. 

Now,  what  are  the  facts  ?  When  the  dam  was  first  placed  and  the 
parts  dried,  all  seemed  well.  As  soon  as  the  engine  was  used,  moist- 
ure appeared,  recurring  a  second  time.  Lastly,  the  spunk  and  hot  air 
made  all  dry  once  more,  and  the  eye,  watching,  could  detect  no 
moisture.  Therefore  the  mind  reasoned,  "No  leak."  Nevertheless 
there  was  a  leak,  or  else  how  did  moisture  twice  recur?  The  nature 
of  this  leakage  will  be  explained  in  a  moment,  but  just  here  I  must 
elucidate  this  enigma  and  show  its  relation  to  the  subsequent  failure 
of  the  filling  ;  otherwise  it  will  be  said,  ' '  A  leak  which  did  not  interfere 
with  the  operation  of  filling  was  of  no  consequence." 

When  the  dam  was  first  placed  and  the  parts  dried,  all  moisture 
seemed  to  have  been  excluded.  This  simply  meant  that  the  dam  was 
effectual  as  long  as  the  parts  were  in  a  state  of  rest.  Then  the  engine- 
bur  was  used,  and  moisture  appeared.  This  is  accounted  for  by  the 
statement  that  whenever  a  patient  is  hurt.,  fluids  are  discharged  into  the 
mouth,  whether  by  nervous  or  by  muscular  action  is  immaterial.  The 
fact  is  the  important  thing,  and  it  is  a  fact.  Thus  after  the  use  of  the 
hot-air  blast,  the  parts  being  at  rest,  all  seeming  dry  the  operator 
proceeded.  In  doing  so  he  made  pressure  upon  the  tooth,  which 
caused  pain,  thereby  inducing  a  further  ingress  of  moisture.  The 
pain  of  packing  the  gold  being  less  than  that  of  using  the  bur,  the 
fluid  accumulates  more  slowly.  Thus  it  does  not  interfere  with  the 
placing  of  gold  along  the  extent  of  the  border.  About  this  time, 
however,  moisture,  unseen,  slowly  dampens  the  gold  at  this  point,  so 
that  a  tiny  pellet  would  not  cohere.  But  the  operator  is  not  using 
tiny  pellets,  but  pieces  of  some  size,  which  he  first  attaches  to  the  zinwet 
gold  within  the  cavity,  and  then  mallets  down  over  the  border.  Thus 
it  may  happen  that  each  piece  of  gold  coheres  along  a  portion  of  its 
extent,  so  keeping  its  place,  while  there  is  no  cohesion  whatever  along 
the  gingival  border.  Such  a  filling  may  be  polished  and  burnished  so 
as  to  present  a  fine  appearance,  but  there  is  a  weak  spot,  and  it  is 
along  the  gingival  border,  where  the  leak  allowed  a  slight  percolation 
of  moisture. 

I  must  now  explain  the  existence  of  a  leak  which  is  undiscernible  by 
the  eye,  and  yet  allows  the  entrance  of  moisture.  It  most  often  occurs 
because  of  the  fact  that  the  hole  punched  for  the  passage  of  the  tooth 
is  made  too  large.     In  a  very  wet  mouth,  if  the  dam  is  slipped  over  a 


LEAKAGE. 


43 


tooth  readily,  the  chances  are  that  one  of  these  invisible  leaks  will 
occur.  Therefore,  in  such  mouths  the  holes  should  be  cut  so  small 
that  they  just  escape  tearing  when  stretched  over  the  teeth.  In  this 
manner  the  tooth  is  hugged  so  tightly  that  the  contractile  action  of 
the  rubber  compels  it  to  reach  as  small  a  diameter  as  possible,  which 
is  found  up  under  the  gum-margin,  because  of  the  conical  shape  of 
roots.  Of  course  in  a  dry  mouth  any  tendency  to  leakage  caused  by 
a  loosely-binding  dam  may  be,  and  usually  is,  overcome  by  the  liga- 
ture. In  the  case  above  described,  where  there  was  barely  room  for 
the  silk  above  the  border  of  the  cavity,  the  ligature  itself  operated 
against  the  discovery  of  the  cause  of  leakage,  while  it  in  no  way  pre- 
vented the  excessive  moisture  from  creeping  under  it,  and  immediately 
upon  the  gold. 

Another  cause  of  leakage  is  seen  in  Fig.  56,  which  shows  the  dam 
over  two  teeth  whose  crowns  are  omitted  in  order  that  the  points  of 
leakage,  a,  may  be  more  readily  seen.     Here  the  fault  has  not  been 

Fig.  57. 


that  the  holes  were  made  too  large,  but  insufficient  space  was  left  be- 
tween them,  and  the  stretching  necessary  to  place  the  dam  over  two 
teeth  has -produced  a  space  next  to  each,  as  pictured.  Of  course  this 
may  be  avoided  by  proper  spacing.  In  the  next  diagram,  however. 
Fig.  57,  is  shown  a  similar  difficulty  arising  from  a  different  cause. 
Here  a  section  through  the  teeth  near  the  gum-line  discloses  a  distinct 
concavity  along  the  approximal  surfaces.  The  dam  stretched  over 
such  a  tooth  must  follow  a  straight  line  from  the  points  b,  b,  so  that  a 
space  is  unavoidably  left.  The  question  arises.  Can  the  dam  be  placed 
here  so  as  to  avoid  leakage  ?  Moisture  cannot  be  kept  out  by  the 
dam  alone,  but,  the  condition  being  recognized,  a  roll  of  cotton  dipped 
in  sandarac  varnish  should  be  packed  along  the  leak  ;  then  a  ligature 
should  be  knotted  so  as  to  present  three  or  four  knots,  which  should 
be  placed  over  the  cotton  and  the  silk  then  firmly  tied  around  the 
neck  of  the  tooth.     In  a  few  moments  all  leakage  ceases. 

Another  occasional  source  of  leakage  is  where,  in  placing  the  dam 
so  as  to  include  a  molar,  the  edge  is  not  forced  between  the  teeth  at 


44 


METHODS  OF  FILLING   TEETH. 


Fig.  58. 


the  posterior  border  of  the  molar.  The  clamp  is  placed,  and  all  seems 
well,  but  in  a  wet  mouth  moisture  will  inevitably  creep  in.  Indeed, 
there  are  many  instances  where  leakage  will  occur  about  a  clamp 
which  will  cease  if  the  clamp  be  removed  and  a  ligature  tied  about  the 
tooth  before  replacing  it.  Again,  it  may  happen  that  there  is  a  space 
along  a  palatal  or  labial  surface  of  a  molar  similar  to  that  shown  in 
Fig.  57,  as  occurring  at  the  approximal  side.  .  This  is  seldom  found 
in  normal  conditions,  but  often  occurs  where  there  has  been  recession 
which  reaches  the  bifurcation.  In  these  cases  the  roll  of  cotton 
dipped  in  sandarac  should  be  laid  over  the  part,  and  held  in  position  by 
the  jaws  of  the  clamp,  which  are  pressed  against  it. 

A  slight  tear  in  the  dam,  occurring  at  a  time  when  the  filling  is  so 
far  advanced  that  the  dam  cannot  be  renewed,  may  some- 
times be  remedied  by  dipping  a  piece  of  sponge  in  sandarac, 
and  then  forcing  it  into  the  hole.  The  same  thing  may  be 
accomplished  by  making  a  button  of  wood,  as  shown  in 
Fig.  58,  which  may  be  whittled  in  a  moment  from  a  piece  of  orange- 
wood. 

The  best  course  is  not  to  tear  the  dam.  In  using  a  sand-paper 
disk,  if  the  edge  is  allowed  to  run  over  a  piece  of  soap  it  will  not  cut 
the  dam,  and  is  less  likely  to  become  entangled  in  the  folds  of  rubber. 
The  dam  is  frequently  cut  with  the  sharp  points  of  clamps,  so  that 
care  should  be  exercised  in  that  direction.  ^ 

The  NcLpkin. — The  small  napkin  made  into  a  roll  I  find  much  use 
for  in  the  lower  jaw,  but  seldom  upon  the  upper.      It  should  be  about 

three  inches  square  and 
without  fringe.  In  all 
ordinary  cases  it  may  be 
folded  into  a  roll  and  ap- 
/0\        ll^\  l^  ^  -"     A        plied   about  the*  teeth  in 

the  form  of  a  horseshoe — 
the  ends  forward.  It  is 
readily  held  in  position 
with  the  mouth-mirror. 
In  operations  on  the  lower 
^^'  ^4-  molars  which  will  not  re- 

quire much  time,  the  tooth  can  be  kept  absolutely  dry  by  use  of  a  small 
napkin  applied  in  the  above  manner,  but  further  secured  by  using  the 
clamp  (Fig.  59).  The  side  pieces  hold  the  tongue  out  of  the  way,  and 
to  some  extent  prevent  suction,  so  that  little  if  any  saliva  enters  the 
mouth  through  the  ducts  of  the  submaxillary  glands.  The  jaws  of 
the  clamps  admirably  fit  the  lower  molars,  and  usually  remain  rigidly 
in  place. 


Fig.  59. 


CONTROL  OF  MOISTTRE.  45 

Sometimes  the  only  necessity  for  using  a  napkin  is  the  fact  that  the 
patient  is  oversensitive  and  easily  nauseated  by  the  dam.  If  there  is 
danger  of  moisture  arising  between  the  teeth,  a  piece  of  rubber-dam 
just  large  enough  to  cover  the  two  teeth  and  immediate  vicinity  may 
be  placed  without  inconvenience  to  the  patient,  and  then  the  napkin 
in  combination  with  this  will  keep  all  perfectly  dry  for  a  short  time. 

Where  I  use  a  napkin  in  the  upper  jaw,  I  simply  fold  a  large  nap- 
kin once,  so  as  to  present  a  doubled  edge,  and  pass  this  back  behind 
the  tooth  to  be  filled,  holding  it  with  the  mouth-mirror.  This  is  less 
annoying  to  the  patient  than  any  other  method,  and  will  keep  a  crown 
cavity  dry  long  enough  to  insert  gold.  I  have  filled  the  posterior 
approximal  surfaces  of  wisdom-teeth  in  this  way,  producing  permanent 
gold  fillings.  This,  however,  is  the  most  difficult  place  for  using  a 
napkin,  owing  to  the  fact  that  the  muscles  offer  tremendous  resistance. 

Chloro- Percha  and  other  Devices  for  Controlliyig  Moisture. — Chloro- 
percha  may  be  made  to  serve  a  very  useful  purpose  at  times.  A  case 
may  arise  where  it  is  impossible  to  apply  a  clamp  to  a  festoon  cavity, 
which  is  nevertheless  so  small  that  it  could  be  quickly  filled  if  only 
kept  dry  ;  a  napkin  will  not  serve,  for,  though  it  might  be  made  to 
dam  up  the  saliva,  there  is  often  a  weeping  of  mucus  from  the  mem- 
brane overhanging  the  cavity,  and  this  is  sufficient  to  prevent  the  in- 
sertion of  a  cohesive  gold  filling.  If  the  gum  be  wiped  as  dry  as  possi- 
ble, and  then  smeared  with  a  thin  coating  of  chloro-percha,  the  cavity 
may  be  filled  successfully  by  a  skillful,  rapid  operator. 

There  is  a  device  of  which  I  have  made  frequent  use,  but  which  I 
believe  is  now  difficult  to  obtain.  It  consisted  of  a  sort  of  clamp,  which, 
however,  was  not  needed,  and  concaved  disks  of  pipe-clay.  It  is 
well  known  that  a  fresh  clay  pipe  will  stick  to  the  lips.  These  disks, 
made  of  the  same  material,  could  be  placed  over  the  orifice  of  the  duct 
of  Steno,  and  would  adhere,  shutting  off"  that  supply  of  saliva  for  an 
hour  or  two.      In  many  cases  they  prove  most  useful. 

Many  use  Japanese  bibulous  paper  for  damming  up  saliva.  Its 
advantage  over  the  napkin  is  that  like  the  clay  disk  it  adheres  to  the 
mucous  membrane,  but  it  absorbs  moisture  more  rapidly.  For  short 
operations,  however,  it  is  frequently  a  good  plan  to  make  a  stiff"  roll 
of  this  paper  and  stuff"  it  between  the  cheek  and  alveolar  process,  thus 
covering  the  opening  of  the  duct. 

There  are  little  rolls  of  cotton  which  are  now  sold  for  this  same  pur- 
pose, and  are  useful. 

Wedges  vs.  Separators. — I  have  the  boldness  to  assert  that  steel 
separators  have  worked  more  harm  than  good  to  the  profession.  I 
have  no  doubt  that  in  the  hands  of  the  most  skillful,  and  used  with 
discriminating  judgment,  they  have  saved  much  time  for  this  limited 
class  ;  but  in  the  practice  of  the  many  the  result  has  been  too  often  the 


46  METHODS  OF  FILLING   TEETH. 

filling  of  teeth  with  insufficient  space.  The  man  does  not  live  who 
can  fill  as  perfectly  in  a  narrow  crevice  as  he  could  in  an  approximal 
surface  fully  exposed  by  the  loss  of  a  tooth.  It  follows  logically  that  as 
much  space  should  be  obtained  as  is  possible  without  permanent 
injury. 

There  are  several  reasons  why  a  perfect  filling  cannot  be  made 
where  the  space  is  very  slight,  but  the  chief  one  is  that  gold  should  be 
built  out  so  far  beyond  the  true  surface,  and  over  all  borders,  that  the 
final  finishing  will  cut  down  to  a  perfectly  condensed  part  of  the  gold. 
For  this  reason,  where  teeth  are  forced  apart  with  steel  separators,  it 
often  happens  that  the  fillings  when  finished  show  pitting,  or  at  best 
will  not  take  a  mirror-like  polish,  which  should  be  made  on  all,  but 
more  especially  upon  those  in  approximal  surfaces. 

There  are  two  kinds  of  cavities  which  require  considerable  space. 
These  are  very  small,  and  very  large  cavities.  To  fill  a  tiny  cavity 
through  a  narrow  crevice  is  to  court  failure,  while  it  is  simply  impos- 
sible to  reach  into  all  parts  of  large  cavities,  in  long  bicuspids,  without 
considerable  room.  In  the  latter,  all  that  part  which  is  most  inac- 
cessible is  improperly  filled,  but  being  also  out  of  sight  is  not  seen 
by  the  patient,  and  not  looked  at  too  closely  by  the  dentist,  who 
thinks  he  cannot  afford  the  time  required  for  properly  separating  teeth. 

If  it  is  important  to  fill  a  tooth  at  all,  it  is  important  to  fill  it  well, 
and  to  fill  it  well  the  cavity  must  be  accessible.  This  can  only  be  ac- 
complished by  separating  as  widely  as  is  consistent  with  safety.  The 
cases  where  teeth  can  be  forced  as  far  apart  (with  the  patient' s  con- 
sent) by  using  a  separator,  as  by  the  old-fashioned  system  of  wedging, 
are  so  few,  that  to  buy  a  separator  seems  to  me  to  throw  away  money, 
for  I  refuse  to  insert  gold  with  insufficient  room  for  thorough  work. 

Where  the  patient  is  easily  hurt,  if  there  is  no  hurry,  the  teeth  may 
be  painlessly  forced  apart  with  tape.  The  patient  should  be  supplied 
with  this  and  directed  to  change  it,  increasing  the  number  of  thick- 
nesses from  day  to  day  until  the  space  is  adequate. 

The  rubber  wedge  is  the  most  positive,  and  at  the  same  time  the 
most  painful,  usually  making  the  teeth  so  sore  to  the  touch  that  they 
must  be  allowed  to  rest  for  several  days.  This  necessitates  the  re- 
moval of  the  wedge  and  the  insertion  of  a  piece  of  gutta-percha. 
This  is  placed  between  the  teeth  cold,  trimmed  just  thick  enough  to 
slightly  wedge  when  pressed  in.  With  a  warm  burnisher  the  surplus 
is  then  removed  on  each  side,  and  the  soreness  will  subside  very  rap- 
idly, the  teeth  meanwhile  being  kept  apart.  The  main  objection  to 
rubber  is  the  tendency  to  slide  up  against  or  under  the  gum.  This 
may  usually  be  prevented  by  allowing  a  bit  of  the  wedge  to  extend 
beyond  the  cutting-edges  of  the  teeth.  Sometimes  it  is  well  to  apply 
the  dam,  smear  the  teeth  lightly  with  sandarac,  and  then  place  the 


MA  l^RICES.  47 

wedge,  after  which  it  will  not  be  apt  to  slip.     The  dam  can  be  removed 
by  first  cutting  the  septum  of  rubber  between  the  teeth. 

Where  it  can  be  used,  I  like  the  wooden  wedge  better  than  any 
other.  To  apply  it,  first  cut  a  thin  wedge,  soap  it,  and  slip  it  between 
the  teeth  next  to  the  gum.  Next  trim  the  wedge  proper  with  a  long 
taper,  soap  it,  and  force  between  the  teeth,  driving  it  into  place  with 
gentle  taps.  After  cutting  off  the  ends,  withdraw  the  wedge  which 
was  first  placed,  thus  relieving  the  pressure  against  the  gum. 

Whenever  there  is  sufficient  space  above  the  gingival  margin  of  the 
cavity  to  permit  it,  a  wedge  should  be  forced  between  the  teeth  during 
the  operation  of  filling.  This  not  only  supports  the  teeth,  lessening 
the  shock  from  the  mallet  blows,  but  it  protects  the  dam  when  the 
disk  is  used.  This  wedge  should  be  made  thin  and 
shaped  as  seen  in  Fig.  60.  The  grooves  at  each  side  ^^'  °'  ^^  °  ^' 
make  it  more  firm,  and  prevent  it  from  riding  up. 
As  the  wooden  wedge  is  not  always  entirely  satisfac- 
tory, owing  to  the  fact  that  if  proper  grooves  be  cut 
it  sometimes  becomes  difficult  or  impossible  to  force 
it  into  place,  I  have  devised  a  steel  wedge  which 
serves  admirably  in  most  cases.  This  is  shown  in 
Fig.  60  a.  It  is  similar  in  general  shape  to  the  wooden  wedge,  but  a 
V-shaped  cut  forms  the  sides  into  two  arms  which  can  be  sprung 
together,  and  so  forced  into  place,  where  it  is  retained  by  the  strength 
of  the  spring.  It  will  be  noticed  that  this  has  a  tendency  to  further 
separate  the  teeth  ;  this  is  slight,  and  no  disadvantage. 

The  Uses  and  Dangers  of  Matrices. — If  separators  have  worked 
evil,  matrices  have  proved  even  a  more  disastrous  delusion.  It  seems 
so  easy  to  prove  that  a  tooth  which  has  been  encircled  by  a  matrix 
cannot  be  properly  filled  with  gold,  that  it  is  astonishing  that  so  many 
really  skillful  men  use  them. 

The  argument  is  this  :  What  is  the  principle  upon  which  a  matrix 
is  used  ?  It  is  made  to  supply  a  lost  wall,  and  thus  to  produce  a 
cavity  which  is  practically  similar  to  one  which  has  all  walls  standing, 
which  latter  is  admittedly  the  least  difficult  to  fill.  This  the  matrix 
does,  and  since  the  cavity  which  it  simpHfies  is  usually  most  difficult, 
at  a  casual  glance  it  would  appear  that  the  matrix  is  a  most  valuable 
instrument.  The  fallacy  lies  in  this,  that  while  (perhaps)  it  renders 
the  actual  filling-process  more  simple,  it  forms  the  gold  so  that  it  be- 
comes impossible  to  properly  polish  it.  To  explain  this  the  illustra- 
tion (Fig.  61)  will  serve.  The  matrix  is  seen  drawn  tightly  around 
the  bicuspid.  The  teeth  have  not  been  wedged,  since  no  space  is 
needed  save  for  the  matrix,  which  usually  can  be  crowded  between 
the  teeth  in  their  normal  position  :  indeed,  it  is  usually  preferred  that 
the  teeth  should  be  close  together.      It  seems  to  me  that  the  logic 


48 


METHODS  OF  FILLING  TEETH. 


which  I  am  now  about  to  use  is  simply  unanswerable.  The  tooth 
being  filled,  and  the  matrix  removed,  it  is  certainly  true  that  any  pol- 
ishing done  with  sand-paper  or  file  mtist  rejnove  a  portion  of  the  toothy 
however  little^  and  thus  produce  a  per?nane7it  space.  I  have  refilled 
teeth  because  this  had  been  done.  But  it  may  be  contended  that  it 
is  not  necessary  to  polish  between  the  teeth  when  a  matrix  has  been 
used,  since  the  gold  packed  against  the  matrix  must  be  already 
smooth.  Let  us  consider  this.  I  have  contended  that  all  fillings, 
and  especially  those  in  approximal  surfaces,  should  be  made  as  smooth 
as  a  mirror.  To  produce  such  a  surface  by  simply  packing  gold,  it 
follows  that  the  surface  against  which  the  gold  is  packed  should  be  as 
smooth  as  glass.  This  is  not  true  of  any  matrix,  but  can  this  be 
done?  I  presume  that  few  men  would  claim  more  skill  than  that 
which  was  possessed  by  Dr.  Marshall  H.  Webb.  Several  years  ago 
I  had  the  honor  of  taking  part  in  a  friendly  contest  with  him  and 
several  others,  to  test  various  methods  of  inserting  gold.     We  used 


Fig.  6i. 


Fig.  62. 


different  kinds  of  mallets,  and  filled  glass  tubes  set  in  wood,  these  being 
held  in  place  with  cement.  Here  we  had  practically,  glass  Tnatrices. 
After  the  fillings  were  made  they  were  tested  in  various  ways.  To 
determine  the  adaptation  to  the  walls  (glass)  they  were  placed  in  an 
aniline  dye.  All  of  them  leaked  badly.  They  were  then  removed  from 
the  tubes  and  examined  with  a  magnifying  glass.  All  of  thetn  were 
badly  pitted,  the  pits  showing  plainly  even  to  the  naked  eye.  Thus  it 
follows  that  several  gentlemen,  Dr.  Webb  among  the  number,  failed 
to  make  gold  adapt  itself  to  a  smooth  surface.  Therefore  they  could 
not  pack  gold  against  the  smooth  surface  of  a  matrix,  so  that  upon 
the  removal  of  the  matrix  the  gold  would  be  polished.  Who  will 
claim  to  do  in  such  a  case  what  Dr.  Webb  could  not  ?  It  may  be 
asked.  If  these  fillings  leaked,  why  do  not  fillings  in  teeth  leak  ?  The 
answer  is  that  in  the  tooth  the  gold  is  packed  against  a  rough  surface, 
which  by  offering  resistance  makes  it  possible  to  obtain  a  sufficiently 
accurate  adaptation. 

It  will  be  claimed  that  a  matrix  may  be  made  of  a  material  which 
will  yield,  so  that  under  the  force  of  the  mallet  the  gold  will  bulge  be- 
yond the  proper  contour,  and  may  then  be  polished.  This  is  true  of 
the  upper  two- thirds,  but  is  not  true  of  the  gingival  margin.  There 
is  but  one  way  to  produce  a  perfect  approximal  filling  ;  that  is,  to  ob- 


THE   USES  OF   VARIOUS  FTLLING-MATF RIALS.  49 

tain  sufficient  space  so  that  the  gold  may  be  made  to  extend  over  all 
margi7is,  and  bulge  beyond  the  normal  co7itour,  so  that  when  all  is 
trimmed  away  a  perfect  surface  is  prodticed  at  all  parts,  ajid  of  such 
contour  that  the  teeth  rcturjiing  to  normal  position  will  knuckle.  This 
is  impossible  with  a  matrix. 

There  is  no  objection  to  using  a  matrix  around  a  tooth  when  the 
cavity  is  next  to  a  space  made  by  the  loss  of  a  tooth  (Fig.  62),  for  here 
the  fining  may  be  polished,  the  slight  loss  of  tooth-substance  being  of 
no  consequence.  The  greatest  use  for  a  matrix  is  where  a  large  part 
of  a  tooth  must  be  contoured  with  amalgam,  for  this  is  a  material 
which,  because  of  its  plasticity,  would  be  most  difficult  to  use  without 
the  support  which  the  matrix  gives.  Moreover,  it  is  a  material  which 
can  be  polished  with  very  little  loss  of  substance.  Where  it  is  possible, 
the  matrix  should  be  allowed  to  remain  in  place  twenty-four  hours. 

To  sum  up,  a  matrix  is  invaluable  when  amalgam  is  to  be  inserted, 
and  disadvantageous  where  gold  is  to  be  employed. 


CHAPTER    III. 

The  Uses  of  Various  Filling-Materials — Methods  of  Manipulation 
— Materials  of  Minor  Value — Gutta-percha — Oxychloride  of 
Zinc — Oxyphosphate  of  Zinc — Amalgams — Copper  Amalgam — Gold. 

An  endless  variety  of  materials  has  been  suggested  for  replacing 
the  portion  of  a  tooth  which  has  been  lost  by  caries.  But  few  have 
proven  of  great  value,  and  no  one  material  has  been  found  to  satisfy 
the  demands  of  all  cases.  It  is,  however,  no  more  necessary  for  the 
dentist  to  rely  upon  one  filling-material  than  it  is  for  the  physician  to 
use  one  drug  with  which  to  control  all  the  diseases  of  mankind.  We 
can  intelligently  care  for  all  conditions,  provided  we  have  at  least  one 
method  which  will  be  useful  in  each  given  condition. 

There  is  but  one  material  which  is  best  adapted  for  the  filling  of  a 
given  cavity  at  a  specified  time.  Let  2cs  use  that  specially  indicated 
material  on  every  occasion,  even  if  we  should  lose  by  the  transaction. 
Let  us  refuse  to  use  amalgam  where  gold  should  be  employed,  and 
equally  let  us  fill  with  amalgam  if  best,  even  though  the  patient  would 
pay  more  for  gold.  Few  would  deny  the  wickedness  of  placing  a 
number  of  amalgam  fillings  in  the  incisor  region,  yet  if  gold  can  be 
used  to  best  advantage  it  is  equally  wrong  to  improperly  fill  bicuspids 
and  molars  with  some  other  material. 

If  one  is  to  follow  this  rule  of  never  filling  except  with  that  which 

4 


50  METHODS  OF  FILLING    TEETH. 

is  best  adapted  to  the  circumstances,  it  becomes  necessary  for  him  to 
be  able  to  determine  for  all  cases  what  material,  or  combination  of 
materials,  is  best  fitted  to  the  occasion.  Therefore,  in  speaking  of  the 
various  materials,  I  shall  endeavor  to  state  where  each  is  positively- 
indicated,  and  leave  the  reader  to  discriminate  for  himself  in  less 
obvious  positions. 

The  main  reliance  of  dentists  is  upon  gutta-percha,  the  plastics,  and 
gold,  but  there  are  other  materials  which  have  been  used,  and  of 
them  I  will  make  cursory  mention. 

Materials  of  Minor  Value. — Lead  has  been  used  in  children's  teeth, 
and  occasionally  in  well-defined  cup-shaped  cavities  in.  adult  mouths. 
Thin  sheets  of  the  metal  are  cut  up  into  narrow  strips  and  rolled  into 
convenient  sizes.  They  are  retained  in  place  by  a  process  of  wedging. 
This  at  once  limits  the  cavities  in  which  lead  may  be  used  to  those 
having  well-defined,  strong  surrounding  walls.  If  omitted  from  the 
office,  I  believe  it  would  never  be  missed.* 

Tin  has  been  used  similarly  to  lead,  with  no  special  advantage.  It 
has  also  been  made  into  foil  and  used  as  soft  or  non-cohesive  fillings 
are  made.  Before  the  introduction  of  amalgam,  it  occupied  the  same 
place  which  that  material  too  often  does  now,  for  the  filling  of  teeth 
where  a  high  fee  could  not  be  charged.  Except  for  this  purpose,  which 
is  an  unprofessional  one,  it  has  little  value.  Latterly,  in  combination 
with  gold,  it  has  been  claimed  to  have  special  therapeutic  effects  not 
possessed  by  either  metal  alone.  It  is  doubtful  if  this  claim  can  be 
proven  to  be  well  founded.     I  will  say  piore  of  it  when  considering  gold. 

Porcelain  fillings  are  intended  to  supply  the  esthetic  demand  for  a 
material  which  will  accurately  resemble  the  lost  tooth  bone  which  it 
replaces.  The  first  efforts  in  this  direction  were  in  the  form  of  inlays. 
Portions  of  porcelain  teeth  were  utilized,  and  were  ground  to  approxi- 
mately fit  the  cavity.  This  was  tedious  and  unsatisfactory.  Later 
rods  of  baked  porcelain  were  supplied  by  the  dealers,  of  various  cir- 
cumferential shapes.  The  fitting  was  attained  mainly  by  shaping  the 
cavity  to  receive  the  end  of  the  rod.  A  piece  of  the  proper  thick- 
ness was  then  cut  off"  with  a  diamond  disk  and  set  in  place  with 
cement.  Later  still  the  dealers  gave  us  bits  of  porcelain  approximat- 
ing the  shapes  of  common  cavities,  especially  such  as  occur  on  the 
labial  surfaces  of  incisors.  All  of  this  class  of  work  loses  its  main 
advantage  because  the  surface  must  be  ground  flush  with  the  cavity, 
so  that  while  the  inlay  may  somewhat  resemble  the  tooth  in  color, 
it  lacks  the  luster  of  enamel. 

The  next  attempt  was  in  the  direction  of  baking  porcelain  espe- 
cially to  fit  the  cavity.  For  this  purpose  a  matrix  was  made  with  thin 
platinum,  and  the  body  was  baked  upon  it  in  a  small  gas  furnace.     It 

*  I  am  not  here  considering  the  filling  of  root-canals. 


PORCELAIN  FILLINGS.  51 

was  soon  discovered  that  the  thickness  of  the  platinum  matrix  was 
such  that  a  bad  seam  would  show  when  the  filling  was  in  place,  and 
moreover  it  was  next  to  impossible  to  certainly  obtain  the  color  re- 
quired, because,  with  the  regular  porcelain  body,  variations  in  heat 
produce  variations  in  color.  To  obviate  this  objection  powdered  glass 
was  next  tried.  In  this  manner  a  body  was  obtained  which  could  be 
fused  in  a  pure  gold  matrix,  over  an  alcohol  lamp,  and  the  colors  could 
be  fairly  well  relied  upon.  But  these  vitreous  fillings  lacked  strength 
and  were  easily  crushed  during  mastication. 

From  these  various  attempts,  however,  there  has  finally  been  evolved 
a  process  which  in  many  cases  will  be  found  useful  and  durable.  A 
low -fusing  porcelain  body  may  now  be  had,  reliable  in  color,  readily 
manipulated,  strong  and  of  artistic  appearance.  It  is  put  up  in  small 
bottles,  each  containing  one  shade,  and  some  fifty  or  more  shades 
may  be  had. 

In  making  a  porcelain  filling  of  this  class,  the  procedure  is  as  fol- 
lows :  First,  the  dam  being  in  place,  the  cavity  is  to  be  cleansed  of 
decay  and  prepared  without  undercuts.  If  the  cavity  be  deep,  so 
that  undercuts  are  unavoidable  without  sacrifice  of  valuable  tooth 
bone,  it  should  be  temporarily  filled  with  oxyphosphate,  and  then, 
after  this  has  fully  set,  a  cavity  may  be  prepared  which  is  of  suitable 
depth.  Whatever  may  be  the  true  solution  of  beveling  or  not  bevel- 
ing margins,  when  preparing  for  a  gold  filling,  there  can  be  no  possi- 
ble room  for  discussion  if  a  porcelain  filling  is  desired.  The  margins 
should  be  sharply  defined  and  absolutely  free  from  bevel  ;  the  walls, 
however,  from  the  bottom  of  the  cavity  to  the  edges  should  be  slightly 
slanted  so  that  the  matrix  may  be  readily  withdrawn. 

The  matrix  is  formed  with  rolled  gold  No.  30.  A  piece  is  cut 
slightly  larger  than  the  cavity  and  must  then  be  accurately  forced  into 
it  and  against  the  walls  at  all  points,  especially  along  the  margins. 
Even  with  the  simplest  and  most  accessible  cavities,  this  will  require 
nicety  of  touch  and  skillful  handling,  while  in  some  of  the  more  inac- 
cessible situations  it  will  try  the  skill  of  the  most  expert  to  produce 
a  perfect  result.  The  first  rule  may  be  tersely  stated:  Proceed  slowly. 
All  efforts  to  hurry  this  portion  of  the  work  will  result  in  loss  of  time, 
and  perhaps  of  temper.  In  my  experience  the  best  method  of  forming 
the  matrix  has  been  with  small  pieces  of  spunk.  The  first  piece  may 
be  of  fair  size,  but  should  be  forced  against  the  gold  very  gently,  no 
effort  being  made  to  immediately  press  that  piece  into  position.  This 
piece  should  be  held  in  place  with  a  small  smooth  ball  burnisher  in  the 
left  hand.  A  second  and  a  third  piece  of  spunk  follows,  each  placed 
with  gentle  pressure  only,  and  so  on,  as  though  filling  the  cavity,  until 
the  cavity  is  quite  full.  Then  it  will  be  noted  that  the  edges  of  the  gold 
stand  up,  and  are  possibly  wrinkled.     Still  holding  the  spunk  in  place 


52  METHODS  OF  FILLING   TEETH. 

lightly  but  firmly  with  the  burnisher,  a  larger  bit  of  spunk  is  grasped 
with  the  foil-carriers,  and  all  the  protruding  parts  of  the  gold 
"wiped"  to  place,  at  first  quite  gently,  so  that  it  lies  against  the  sur- 
face of  the  tooth  smoothly.  Now  with  a  larger  ball  burnisher  the 
spunk  within  the  cavity  is  forcibly  compressed,  driving  before  it  the 
gold,  and  thus  pressing  it  against  all  parts  of  the  cavity.  Great  care 
is  requisite  not  to  tear  the  matrix,  at  the  bottom  of  the  cavity, — an 
accident  always  to  be  avoided,  though  not  absolutely  preventing  the 
continuance  of  the  process.  Examination  of  the  matrix  along  the 
borders  will  usually  disclose  the  fact  that  the  gold  is  not  lying  close 
against  the  surface  at  all  parts.  A  few  of  the  pieces  of  spunk  may 
now  be  removed,  and  the  remaining  pieces  held  firmly  with  the  bur- 
nisher, while  with  a  piece  of  spunk  in  the  tweezers  the  operator  with 
a  wiping  motion  perfects  the  adaptation  of  the  matrix  at  all  points 
now  in  view,  more  particularly  along  the  marginal  edges,  which  should 
be  as  sharp  as  possible  without  tearing  the  gold.  This  done,  all  the 
spunk  is  taken  from  the  cavity,  and  one  large  piece  placed  over  the 
perfected  part  and  held  there,  while  the  other  portion  is  similarly  per- 
fected, the  gold  being  wiped  to  place  as  before.  The  matrix  should 
now  appear  as  though  the  cavity  had  been  gold-plated,  and  if  the 
adaptation  is  accurate  it  will  require  deft  handling  to  remove  the 
matrix  without  alteration  of  shape.  If  the  cavity  has  been  properly 
shaped,  however,  this  may  be  done.  I  cannot  express  it  better  than 
to  say  that  the  matrix  must  be  ' '  teased' '  out  of  the  cavity.  It  should 
be  touched  ever  so  lightly,  first  at  one  point  and  then  at  another  along 
the  margin  until  it  is  loosened.  While  doing  this  the  operator  should 
watch  closely  to  observe  any  alteration  of  shape  which  might  occur, 
for  should  this  happen  the  matrix  must  be  pressed  back  to  place 
again,  and  made  perfect  with  the  spunk.  The  matrix,  when  loosened, 
is  tipped  gently  out  of  the  cavity  with  an  instrument  until  it  may  be 
safely  lifted  out  with  the  foil-carriers  and  placed  upon  a  bit  of  card- 
board, which  may  serve  as  a  tray  upon  which  to  take  it  to  the  labora- 
tory, where  the  porcelain  is  to  be  baked  in  it.  In  cases  of  unusual 
difficulty,  smearing  the  cavity  lightly  with  powdered  talc  facilitates 
the  removal  of  the  matrix. 

If  the  Downie  bodies  and  furnace  are  to  be  used,  a  platinum  matrix 
will  be  needed.  The  platinum  being  much  thicker  than  the  gold 
foil,  and  more  difficult  to  manipulate,  the  impression  obtained  there- 
with will  be  less  accurate,  and  the  final  fit  of  the  filling  will  be  less 
satisfactory.  With  the  gold  foil  matrix,  and  the  improved  forms  of 
low-fusing  porcelains  now  procurable,  teeth  may  be  filled  so  that  the 
eye  cannot  detect  the  seam  Whilst  the  expert  may  manage  the 
delicate  matrix  without  alteration  of  shape,  it  will  be  best  at  first  to 
invest  it  in  the  muffle,  using  powdered  asbestos  and  water. 


POR CELAIN  FILLINGS.  53 

In  mixing  the  body,  it  has  been  usually  recommended  to  use  water, 
but  much  better  results  will  be  obtained  with  absolute  alcohol.  The 
invested  matrix  is  placed  near  the  slab,  on  which  the  powdered 
body  is  mixed  to  a  creamy  consistence  with  alcohol,  and  carried  to 
place  with  a  very  small  camel' s-hair  brush.  The  body  should  be 
mixed  thin  enough  to  flow  readily  and  thoroughly  cover  the  bottom 
of  the  matrix  as  well  as  the  sides.  Bibulous  paper  should  be  rolled 
into  thin  ropes  and  cut  into  pieces  half  an  inch  in  length.  These  will 
be  serviceable  for  removing  the  excess  of  moisture  before  attempting 
to  bake.  Mixed  with  alcohol  and  treated  in  this  manner,  the  body 
will  shrink  much  less  than  where  water  is  used,  especially  an  excess 
of  it.  The  matrix  is  then  placed  in  the  oven,  which  will  be  de- 
scribed, and  the  porcelain  fused  until  it  flows  down  smoothly.  This 
will  occupy  less  than  a  minute.  It  should  then  be  removed,  and  a 
second  portion  of  body  added,  the  filling  now  being  built  up  to  the 
desired  thickness.  Any  desired  contour  may  be  produced  by  adding 
the  body  comparatively  thin  and  then  removing  the  excess  of  mois- 
ture with  the  bibulous  paper  ropes.  Should  the  body  assume  an 
undesired  form,  a  drop  of  alcohol  applied  with  the  brush  will  enable 
the  operator  to  mold  it  to  proper  shape,  the  excess  of  moisture  being 
removed  as  before.  Where  the  tooth  to  be  filled  has  a  very  lustrous 
enamel,  it  may  be  simulated  by  sprinkling  finely  powdered  plate  glass 
over  the  surface  of  the  baked  filling  and  fusing  it,  thus  supplying  a 
veneer  of  glass. 

Where  any  extensive  contour  is  to  be  made,  it  is  often  a  good  plan, 
after  having  fitted  the  gold  matrix  accurately,  to  introduce  some  pure 
beeswax,  and  build  up  the  desired  contour,  as  though  filling  with 
gutta-percha.  Let  us  suppose  that  the  case  is  the  lost  corner  of  a 
central  incisor.  After  restoring  the  contour  with  wax,  the  wax  itself 
must  be  covered  with  the  gold  foil  along  the  palatal  surface  and  partly 
around  the  approximal.  It  is  then  removed,  bringing  away  with  it 
the  matrix.  This  is  invested  in  the  muffle  in  water  and  asbestos,  and 
the  wax  burned  out  over  the  flame  in  the  oven  before  introducing  the 
body.  Where  the  tooth  is  dead,  the  pulp-canal  should  be  utilized  for 
the  reception  of  a  pin.  After  the  matrix  is  molded  into  the  cavity, 
a  platinum  pin  is  forced  gently  through  the  gold  and  up  into  the  root- 
canal.  This  pin  comes  away  with  the  wax  if  that  method  is  pursued. 
Where  the  operator  has  become  so  proficient  that  he  does  away  with 
the  investment  of  his  matrices,  which  he  will  certainly  do  as  soon  as 
possible,  the  pin  may  still  be  utilized.  The  matrix  is  molded  as 
before,  and  the  pin  placed  through  it.  The  pin  is  then  withdrawn 
and  the  matrix  removed.  Just  before  placing  the  body  in  the  matrix, 
the  pin  is  replaced  as  accurately  as  possible,  and  a  very  little  of  the 
body  dropped  around  it  in  the  matrix.     When  this  is  fused  the  pin  is 


54  METHODS  OF  FILLING  TEETH. 

attached,  to  the  matrix,  which  must  now  be  carried  to  the  tooth  again 
and  replaced.  Thus  any  error  of  placing  the  pin  may  be  corrected, 
and  if  the  pin  is  long  enough  it  will  be  easy  now  to  remove  the 
matrix.     The  filling  is  completed  in  the  usual  manner. 

In  cavities  of  such  great  depth  that  it  is  difficult  to  fashion  a  matrix, 
the  cavity  should  first  be  partly  filled  with  cement,  which  is  allowed 
to  set.  One  or  two  small  holes  should  be  pierced  in  the  gold  before 
filling  the  matrix  ;  then,  before  baking  the  filling,  ordinary  tooth 
pins  passed  through  these  holes  produces  a  filling  having  pins  for 
retention.  The  removal  of  the  first  placed  cement  gives  room  for 
these  pins  when  setting  the  filling. 

The  Oven  for  Baking. 

These  low-fusing  bodies  may  be  fused  with  the  blow-pipe,  which, 
however,  is  used  in  connection  with  an  oven  of  such  simple  construc- 
tion that  any  dentist  could  make  one  for  himself  Obtain  some  thin 
sheet  brass  and  construct  a  box  about  three  inches  cube.  This  should 
be  made  with  as  few  joints  as  possible,  and  the  edges  should  be  riveted 
together  rather  than  merely  soldered.  This  box  is  left  open  in  front, 
and  a  circular  hole  about  one  inch  in  diameter  is  cut  in  the  bottom, 
through  which  the  flame  is  to  enter.  If^this  box  is  neatly  lined  with 
asbestos  board  one- quarter  inch  thick,  a  perfect  oven  is  obtained. 
At  the  back  the  oven  should  be  attached  to  a  standard,  which  will 
support  it — about  four  inches  above  the  bench.  In  use,  the  matrix 
is  placed  in  the  muffle  and  simply  held  within  the  oven,  while  the 
blow-pipe  worked  with  the  foot-bellows  supplies  the  flame  through 
the  hole  in  the  bottom.  A  white  heat  may  be  obtained,  and  as  the 
oven  is  entirely  open  in  front,  the  work  is  easily  watched  at  all  stages. 

The  Muffle. 

The  muffle  is  a  small  box  an  inch  long  and  proportionately  wide, 
made  of  pure  platinum.  This  also  should  be  made  with  as  few  seams 
as  possible,  and  should  be  soldered  with  pure  gold.  At  one  end 
should  be  soldered  securely  a  platinum  extension,  to  which  may  be 
fitted  a  long  wooden  handle,  the  platinum  extension  being  long  enough 
so  that  the  wooden  handle  cannot  reach  the  flame  of  the  blow-pipe. 
The  two  sides  of  the  box  should  extend  a  little  higher  than  the  ends. 
When  the  piece  is  to  be  baked,  the  muffle  is  covered  with  mica,  which 
is  held  fast  by  slightly  pinching  together  these  extending  sides. 
Where  the  matrix  is  invested,  nothing  else  is  placed  within  the  muffle  ; 
but  where  the  matrix  is  used  without  investment,  a  layer  of  powdered 
asbestos  is  placed  in  the  bottom  of  the  muffle  as  a  bed.  It  is  under 
such  conditions  that  a  tear  in  the  matrix  becomes  bothersome,  as  the 


PORCELAIN  FILLINGS.  55 

fluxed  body  at  this  point  coming  in  contact  with  the  asbestos,  some 
of  the  latter  may  adhere  to  it. 

Setting  the  Filling. 

When  the  fiUing  is  made,  it  should  be  tried  in  the  cavity  before 
removing  the  gold  matrix,  and  if  found  not  to  be  of  proper  shape,  it 
can  be  baked  again.  If  satisfactory,  the  matrix  is  to  be  carefully 
peeled  off.  If  it  should  adhere  in  some  places,  these  small  bits  are 
easily  torn  off  with  a  rapidly  revolving  bur,  care  being  observed  to 
touch  the  parts  lightly.  It  will  be  found  in  the  majority  of  cases, 
especially  where  a  final  glazing  of  glass  has  been  used,  that  fine  edges 
extend  beyond  the  true  margins  ;  these  are  best  removed  with  a  fine 
cuttle-fish  disk. 

As  the  retention  of  porcelain  fillings  must  depend  mainly  upon 
some  sort  of  cement,  and  as  cement  adheres  best  to  a  roughened  sur- 
face, the  glazed  surface  of  the  filling  should  be  removed  with  a  corun- 
dum wherever  it  is  to  come  in  contact  with  the  cement.  If  there 
is  sufficient  body  to  the  filling,  undercuts  may  be  made  in  it  with  a 
diamond  disk.  The  cement  should  be  thoroughly  mixed  so  as  to  be 
quite  smooth,  and  should  be  as  thin  as  possible  without  destroying 
the  integrity  of  the  mixture.  It  need  scarcely  be  said  that  a  cement 
of  the  most  adhesive  character  is  a  prerequisite.  Retention  grooves 
should  also  be  cut  in  the  cavity.  When  all  is  in  readiness,  the  bottom 
of  the  cavity  should  be  smeared  with  the  cement,  none  being  per- 
mitted to  extend  upon  the  margins.  Experience  will  enable  the 
operator  to  judge  to  a  nicety  how  much  cement  should  be  used,  so 
that  when  the  filling  is  pressed  into  it  the  excess  will  just  ooze  up  and 
fill  all  crevices,  without  much  escaping  along  the  margins.  Where 
too  much  cement  is  used,  the  filling  cannot  be  thoroughly  forced  to 
place,  and  thus  remains  extruding  from  the  cavity.  A  piece  of  nar- 
row tape  having  been  fixed  around  the  tooth  is  now  firmly  tied, 
carrying  the  filling  accurately  into  position  and  holding  it  there. 
This  avoids  the  danger  of  breakage  which  might  result  from  tapping 
the  porcelain  to  place  with  a  bit  of  orangewood  and  a  mallet,  as 
some  have  recommended.  This  tape  should  be  allowed  to  remain 
until  the  subsequent  sitting. 

Porcelain  Fillings  Anchored  with  Gold. 

In  a  case  of  very  extensive  erosion  which  passed  through  my  hands, 
the  cement  proved  to  be  an  unreliable  dependence.  The  teeth  in- 
volved were  the  upper  incisors.  They  were  very  large  teeth,  and  the 
erosion  had  almost  entirely  removed  the  labial  enamel.  The  dentine 
was  very  sensitive,  and  it  seemed  desirable  to  make  very  thin  porce- 
lain veneers.     There  was  little   difficulty  in    making  fillings  which 


56  METHODS  OF  FILLING  TEETH. 

almost  defied  detection,  fitting  accurately  and  matching  well  in  color; 
■but  it  seemed  impossible  to  retain  them  for  any  great  time  with 
cement.  The  veneers  were  so  thin  that  little  or  no  undercutting  could 
be  attempted,  and  even  roughening  the  under  surfaces  with  sharp 
corundums  did  not  cause  the  cement  to  adhere.  After  two  or  three 
months  the  inlays  would  drop  out,  the  cement  remaining  in  the  cavity 
intact.  Many  different  cements  were  used,  but  success  was  elusive. 
Finally  they  were  secured  in  the  following  manner  : 

The  filling  having  been  accurately  formed,  a  very  thin  diamond 
disk  was  used,  and  a  tiny  V-shaped  slot  was  cut  about  the  center  of 
each  approximal  margin.  The  sides  of  these  slots  were  slightly 
beveled.  The  filling  was  then  placed  in  position,  and  with  the  tiniest 
of  rose  burs  a  small  cavity  was  made  in  the  tooth  just  below  each 
slot.  The  porcelain  was  then  set  with  cement  in  the  above  described 
manner,  and  at  the  next  sitting  the  cement  was  carefully  removed 
from  the  slots  and  underlying  cavities,  and  these  were  then  solidly 
filled  with  gold.  These  gold  fillings  were  inconspicuous,  yet  because 
of  the  beveled  sides  of  the  slots  they  served  as  rivets  to  retain  the 
porcelain  fillings. 

A  similar  procedure  will  recommend  itself  where  an  approximal 
cavity  extends  into  the  masticating  surface,  let  us  say  of  a  bicuspid. 
It  will  be  difficult  to  accurately  form  the  matrix  and  remove  it  with- 
out change  of  shape,  and  even  where  this  is  successfully  achieved  it 
will  require  skill  and  experience  in  baking  the  filling  to  have  it  fit 
along  the  masticating  portion  of  the  cavity,  and  to  be  not  too  full. 

In  such  cases  little  or  no  attention  need  be  given  to  this  part  of  the 
filling.  If  it  properly  fits  all  other  portions  of  the  cavity,  restoring 
contour  along  all  parts  that  are  exposed  to  view,  that  part  which 
should  fit  into  the  masticating  portion  of  the  cavity  may  be  freely  re- 
moved with  a  corundum,  and  the  edge  beveled,  so  that  a  gold  filling 
subsequently  placed  in  the  masticating  surface  will  extend  over  this 
bevel  and  aid  in  retaining  the  filling. 

Of  all  kinds  of  fillings,  however,  which  depend  upon  cement  for 
retention  within  a  cavity,  I  am  inclined  to  believe  that  only  temporary 
results  will  be  obtained,  and  the  practitioner  should  be  cautious  in 
making  promises  to  the  patient  in  whose  mouth  he  attempts  what  is 
as  yet  in  an  experimental  stage. 

Gutta-Percha. — No  dentist  can  afiford  to  be  without  this  most  valu- 
able material.  Useful  in  many  ways,  it  is  perhaps  most  useful  for 
temporary  purposes.  In  the  form  known  as  "  temporary  stopping" 
it  is  immensely  valuable.  The  temporary  stopping  is  furnished  in  two 
colors,  presumably  that  the  white  may  be  used  in  conspicuous  posi- 
tions. There  is  a  much  better  advantage  to  be  taken  of  the  two  colors. 
The  pink  should  be  used  only  to  cover  arsenical  dressings,  or  in  such 


GUTTA-PERCHA.  57 

teeth  where  the  condition  demands  that  attention  should  be  given  to 
the  tooth  at  the  next  sitting.  The  white  becomes  useful  fot  teeth 
whose  root-canals  have  been  filled,  or  any  other  condition  where  it  is 
not  absolutely  essential  that  the  particular  tooth  should  be  operated 
upon  immediately,  to  the  exclusion  of  other  possibly  urgent  cases. 
Thus,  when  a  patient  presents,  a  glance  in  the  mouth  tells  much.  A 
temporary  filling,  white  in  color,  the  dentist  may  set  aside  for  the 
time  ;  but  a  pink  one  acts  as  a  signal,  which  would  mean  that  delay 
would  be  dangerous . 

A  temporary  purpose,  which  is  better  served  by  gutta-percha  than 
by  temporary  stopping,  is  where  a  patient  presents  with  a  number  of 
dangerous  cavities  ;  teeth  in  which  a  pulp-exposure  may  occur  at 
any  time.  It  is  impossible  to  fill  them  all  at  one  sitting  with  perma- 
nent materials.  It  is  very  wise,  however,  to  cleanse  them  all  of 
aecay,  and  fill  with  gutta-percha.  Thus  all  is  made  safe  at  once,  and 
the  permanent  fillings  may  be  placed  at  leisure. 

As  a  permanent  filling  gutta-percha  may  frequently  be  depended 
upon.  Either  the  white  or  the  pink  may  be  used,  but  my  experience 
has  been  that  the  pink  is  more  durable  ;  therefore  in  inconspicuous 
places  it  is  to  be  preferred.  Much  of  the  reported  failure  of  gutta- 
percha as  a  permai  ent  filling  may  be  referred  to  faulty  manipulation, 
or  injudicious  choice  of  the  cavity  in  which  to  place  it. 

So  far  as  manipulation  is  concerned,  the  common  practice  of  heating 
the  materii-l  in. the  flame  is  ruinous  to  all  hope  of  permanency.  It 
should  be  heated  on  a  porcelain  disk  held  over  the  lamp,  or  prefer- 
ably over  warm  water  on  a  glass  tray.  A  special  apparatus  of  this 
kind  is  purchasable.  In  placing  gutta-percha  in  a  cavity,  should  the 
cavity  be  a  large  one,  it  may  be  packed  piece  by  piece,  thus  in- 
suring adaptation  to  the  walls,  until  two-thirds  of  the  cavity  is  filled. 
Then  a  single  piece  large  enough  to  complete  it  should  be  used.  In 
smaller  cavities  a  single  piece  should  be  chosen  large  enough  to 
slightly  more  than  fill  the  cavity.  After  the  filling  has  cooled  and  is 
hardened,  the  surplus  should  be  trimmed  oft"  with  a  thin  smooth  bur- 
nisher, or  spatula,  slightly  warmed,  care  being  used  not  to  drag  the 
material  away  from  the  walls.  In  a  few  instances,  as  up  under  the 
gum  margin,  I  have  used  to  advantage  a  tape  dipped  in  chloroform. 

Places  where  gutta-percha  is  positively  indicated  are  extremely 
sensitive  cavities  along  buccal,  palatal,  or  lingual  surfaces,  especially 
where  they  extend  wholly  or  in  part  below  the  gum  margin,  in  molar 
teeth.  Here  the  pink  variety  is  to  be  preferred.  Where  teeth  have 
been  worn  by  ill-fitting  clasps,  so  that  cavities  filled  with  leathery  decay 
have  been  formed,  which  when  cleansed  leave  exposed  hypersensitive 
dentine,  they  are  more  likely  to  be  cured  with  gutta-percha  than  with 
any  other  material.      It  is  better  to  be  obliged  to  renew  the  fillings 


58  METHODS  OF  FILLING    TEETH. 

periodically  than  to  risk  death  to  the  pulp  by  using  a  metal.  Gutta= 
percha  is  not  a  non-conductor,  but  it  is  a  poorer  conductor  than  the 
metals,  and  what  is  more  important,  all  the  tissues  of  the  mouth, 
whether  hard  or  soft,  are  singularly  tolerant  of  it.  Occasionally  a 
patient  will  present  with  a  deep  cavity  in  a  most  inaccessible  approxi- 
mal  surface.  Excavation  makes  it  doubtful  whether  the  pulp  is  nearly 
approached,  or  whether  hypersensitive  dentine  alone  is  the  cause  of  the 
pain.  A  very  wise'  course  is  to  temporize  by  inserting  gutta-percha. 
Too  much  examination  may  expose  a  pulp  in  a  small  cavity,  thus  ne- 
cessitating a  tremendous  sacrifice  of  tooth-substance  for  its  proper 
removal,  whereas  under  a  gutta-percha  filling  this  class  of  teeth  is 
frequently  troublesome  no  longer. 

Gutta-percha  is  often  used  as  a  capping  over  pulps  which  are  nearly 
approached.  Where  this  is  done,  and  the  filUng  completed  with  gold, 
common  sense  will  indicate  the  advisability  of  covering  the  gutta-percha 
with  a  resistant  body  of  oxyphosphate  before  attempting  to  pack  gold 
upon  it.  Many,  however,  would  not  think  this  essential  where  amalgam 
is  to  be  the  final  filling.     It  must  be  remembered  that  gutta-percha  is 


slightly  elastic.  Therefore  where  it  underlies  amalgam  or  other  metallic 
filling  it  must  not  be  so  placed  that  the  superincumbent  filling  rests 
wholly  upon  it.  In  Fig.  63  is  shown  a  cavity  filled  improperly.  The 
amalgam,  «,  rests  upon  the  gutta-percha,  b,  in  such  a  manner  that 
pressure  during  mastication  has  a  tendency  to  compress  the  latter,  al- 
lowing the  amalgam  to  be  driven  downward  away  from  the  walls,  thus 
producing  leakage.  In  Fig.  64  the  arrangement  is  better,  for  the 
amalgam,  a,  is  now  supported  by  the  walls  at  the  points  c,  c,  so  that 
movement  under  pressure  is  rendered  impossible.  Thus  it  becomes 
important  not  to  insert  too  much  gutta-percha  under  another  filling 
in  the  vain  hope  of  obtaining  better  insulation. 

A  solution  of  gutta-percha  in  chloroform,  commonly  known  as 
chloro-percha,  is  useful  for  lining  cavities  before  inserting  a  filling  of 
oxychloride,  thus  preventing  the  pain  from  irritation  by  the  chloride 
of  zinc.  It  is  also  valuable,  and  should  always  be  used  as  a  coating 
for  oxychloride  or  oxyphosphate  fillings  where  the  latter  are  meant  to 
serve  permanently. 

Oxychloride  of  zinc,  as  a  filling-material,  is  much  less  used  than  it  was 
before  the  introduction  of  the  oxyphosphates .    As  a  permanent  filling 


OXYCHLORIDE  OF  ZINC.  59 

it  is  doubtful  whether  there  are  any  conditions  in  which  it  is  to  be  pre- 
ferred to  oxyphosphate.  By  some,  however,  it  is  earnestly  claimed 
that  if  a  plastic  of  this  form  must  be  used  where  erosions  have  occurred, 
the  oxychloride  will  serve  better  than  the  oxyphosphate.  This  is  a 
statement  which  may  be  true,  but  as  yet  it  has  not  been  proven.  It 
may  be  true,  but  before  it  can  be  known  to  be  true  it  must  be  ex- 
plained why  it  should  be  so.  This  will  not  be  possible  until  the 
etiology  of  erosion  is  less  shrouded  in  mystery  than  it  is  at  present. 

One  claim  advanced  is  that  the  chloride  of  zinc,  being  a  powerful 
germicide,  is  advantageous.  Before  we  may  depend  upon  oxychloride 
fillings  for  the  reason  that  chloride  of  zinc  is  germicidal,  it  must  be 
shown  that  this  action  continues  even  after  tinion  with  the  oxide  into  a 
solidified  viass.  Again,  it  must  be  proven  that  there  is  a  relation  be- 
tween bacteria  and  erosion,  and  the  special  bacterium  must  be  isolated. 
Then  it  must  be  shown  that  the  oxychloride  filling  placed  in  a  cavity 
will  cause  a  resistance  to  the  erosive  action  which  may  result  from  the 
presence  of  the  bacterium.  Meanwhile  it  is  hazardous  to  depend  upon 
oxychloride  as  a  permanent  filling  in  cavities  near  the  gum-line.  In- 
numerable instances  have  been  reported  and  observed  where  in  such 
positions  a  seemingly  well-made  filling  has  become  wholly  disinte- 
grated, not  only  allowing  decay  around  it,  but  apparently  itself  decay- 
ing. As  this  special  case,  for  which  this  material  has  been  advocated, 
does  not  really  demand  its  use,  it  would  perhaps  be  better  to  depend 
upon  oxyphosphate  where  a  plastic  for  a  permanent  purpose  must  be 
used. 

Another  advantage  which  this  material  is  said  to  possess  is  the 
power  to  excite  the  tooth-pulp  toward  the  production  of  secondary 
dentine.  The  idea  is  that  in  deep  cavities  where  the  pulp  has  been 
nearly  approached,  but  not  fully  exposed,  if  oxychloride  be  placed  as 
a  capping,  its  therapeutic  action  wall  result  in  a  deposition  of  secondary 
dentine  by  the  pulp,  so  that  the  distance  between  the  pulp  itself  and 
the  bottom  of  the  cavity  is  materially  increased.  Were  this  the  case  it 
w' ould  be  most  fortuitous,  for  no  capping  can  be  so  good  as  tooth-bone 
itself  That  a  pulp  has  the  power  thus  to  protect  itself  is  undoubtedly 
admitted,  but  I  think  I  am  safe  in  saying  that  it  is  a  physiological 
action,  rather  than  pathological.  Under  the  slow  wasting  away  occa- 
sioned by  erosion,  this  new^  barrier  is  thrown  out  so  that  the  pulp  is  con- 
stantly protected  from  the  invasion.  Erosive  action  has  seldom  been 
known  to  expose  a  living  pulp,  but  we  frequently  see  erosions  which 
have  passed  beyond  the  original  limits  of  the  pulp-chamber,  and  into 
the  new  dentine  which  the  pulp  had  formed  as  a  protection.  The 
question  arises,  whether  an  oxychloride  filling  can  induce  the  same 
result  ?  The  difficulty  of  proof  lies  in  this,  that  where  it  did  accom- 
plish this,  there  would  be  little  temptation  to  remove  the  filling  or  the 


6o  METHODS  OF  FILLING  TEETH. 

tooth  for  examination.  Thus  its  failures  can  be  more  accurately 
counted  than  its  successes.  Another  fact  to  be  considered  is,  that  just 
as  in  the  case  of  erosions,  the  physiological  action  of  the  pulp  would 
have  the  same  tendency  toward  self-protection  against  the  advance  of 
ordinary  caries.  Indeed,  where  the  carious  action  happens  to  be  slow 
we  not  infrequently  find  it  aborted  by  the  resistant  quality  of  the  new 
dentirie  formed,  so  that  we  get  what  has  been  termed  ' '  arrested  decay. ' ' 
It  follows  from  this  that  any  filling  whose  action  is  sufficiently  nega- 
tive not  to  interfere  with  the  ordinary  healthy  action  would  seem  to 
produce  the  desired  result,  merely  because  it  does  not  prevent  it.  It 
is  probable  that  where  the  oxychloride  succeeds,  it  acts  just  as  other 
materials  do,  by  not  creating  an  irritation. 

That  an  oxychloride  filling  does  possess  some  therapeutic  qualities 
seems  indicated  by  the  fact  that  it  may  usually  be  depended  upon  to 
lessen  the  sensitiveness  of  dentine  if  left  in  a  cavity  a  month  or  more. 
This  of  course  may  occur  under  one  of  oxyphosphate  simply  because 
the  tooth  itself  has  altered,  but  as  it  has  in  my  observation  occurred 
more  frequently  with  oxychloride  I  deem  it  safe  to  say  that  an  oxy- 
chloride filling  has  an  obtunding  effect. 

The  oxychloride  being  obtainable  whiter  than  oxyphosphates,  is 
preferable  for  lining  discolored  teeth  where  the  walls  are  thin.  Occa- 
sionally it  may  happen  that  it  is  desired  to  line  a  wall,  and  yet  there 
may  be  a  need  to  utilize  as  much  of  the  cavity  as  possible  for  the 
proper  retention  of  the  filling.  The  thinnest  imaginable  layer  of 
oxychloride  may  be  effected  by  smearing  the  wall  with  the  fluid  and 
then  blowing  the  powder  against  it  with  a  chip-blower.  It  should  be 
noted  that  this  is  apt  to  destroy  the  rubber  bulb,  because  the  oxide  of 
zinc  taken  within  the  bulb  acts  deleteriously  upon  rubber,  causing  it  to 
dry  and  crack.     This  may  be  prevented  by  careful  washing  after  use. 

Oxyphosphate  of  zinc  is  invaluable  both  for  permanent  and  for  tem- 
porary purposes.  As  much  depends  upon  the  manner  of  manipulat- 
ing the  material,  I  will  explain  how  best  to  mix  it.  According  to  the 
method  of  mixing,  the  resulting  mass  will  be  either  quick  or  slow  set- 
ting, and  either  dense  or  crumbly. 

First,  then,  as  to  its  setting.  The  best  mixing  slab  is  the  side  of  a 
flat  glass  bottle,  which  should  be  provided  with  a  tightly-fitting  rubber 
stopper.  In  the  winter  months,  with  the  temperature  of  the  room 
at  70°  F. ,  the  bottle  has  no  special  advantage  unless  it  is  desired  to 
make  the  material  set  either  very  slowly  or  very  rapidly.  If  the 
bottle  be  filled  with  ice-water,  the  setting  will  be  slow  in  proportion  to 
the  cold,  and  vice  versa,  if  filled  with  hot  water,  it  will  be  rapid  in  pro- 
portion to  the  heat.  This  is  more  useful  in  summer,  when  all  have 
experienced  much  inconvenience  because  of  the  rapid  setting  of  oxy- 
phosphate, so  that  in  warm  weather  a  bottle  of  ice- water  is  very  useful. 


OXYPHOSPHA  TE  OF  ZINC.  6 1 

In  mixing  the  material,  the  method  must  depend  upon  the  use  to 
which  it  is  to  be  put.  If  a  permanent  filHng  is  desired,  put  the  powder 
and  hquid  upon  the  slab  separately.  With  a  clean,  smooth  spatula 
stir  a  little  of  the  powder  into  the  liquid  until  it  is  incorporated,  pro- 
ducing a  thin  but  well-mixed  material.  Add  more  and  more  of  the 
powder  until  a  thick,  smooth  cream  is  produced.  This,  of  course,  is 
still  too  thin  to  be  used  as  a  filling.  With  the  spatula  continue 
to  work  the  mass,  when  it  will  soon  be  observed  that  it  begins  to 
thicken  and  ball  up  on  the  slab.  It  now  has  a  sticky  quality, 
and  may  be  used  for  setting  crowns  or  bridges,  or  in  such  cavities 
where  its  cohesion  to  the  cavity  walls  is  a  prerequisite.  For  all 
ordinary  fillings  add  more  of  the  powder  (but  never  so  much  as  to 
produce  a  granular  consistency),  and  further  working  will  produce 
a  mass  which  may  be  taken  between  the  fingers  and  worked  as  we 
do  gutta-percha.  Made  into  a  roll,  and  cut  into  pellets  with  the 
sharp  edge  of  the  spatula,  it  is  in  a  most  convenient  form  to  be 
packed  into  a  cavity. 

For  temporary  purposes,  where  it  is  desirable  that  the  filling  may  be 
readily  removed  at  a  subsequent  sitting,  as,  for  example,  where  it  is 
employed  to  cover  an  arsenical  dressing  in  a  shallow  cavity,  after  the 
creamy  stage,  instead  of  kneading  to  produce  thickening,  continue  to 
add  the  powder  until  the  consistency  is  suitable  for  use.  A  mass  thus 
made  may  seem  the  same  as  the  other,  but  really  it  is  quite  different. 
There  is  an  excess  of  the  powder,  and  after  hardening  it  can  be  more 
readily  crumbled  away  with  a  sharp  excavator.  Thus  there  is  a  vast 
difference  between  the  preparation  for  permanent  or  for  temporary 
purposes.  May  not  some  of  the  failures  recorded  against  the  material 
be  more  properly  attributable  to  its  faulty  manipulation  ? 

It  has  been  advised  that  during  the  mixing  some  germicide  should 
be  worked  into  the  filling.  In  this  way  oil  of  cloves  and  other  medica- 
ments can  be  stirred  in  with  no  apparent  harm  to  the  material.  More- 
over, the  odor  of  the  disinfectant  will  be  noticeable  very  long  after,  but 
whether  there  be  any  advantage  in  the  process  remains  to  be  demon- 
strated. 

Oxyphosphate  as  a  filling-material  has  many  uses,  the  most  impor- 
tant of  which  is  as  a  mass  to  be  interposed  between  a  metal  filling  and 
the  tooth  itself.  It  must  be  remembered  that  save  in  rare  cases  gold 
or  amalgam  furnishes  no  support  to  frail  walls.  In  fact,  the  metallic 
filling  depends  largely  upon  the  strength  of  the  cavity  walls  for  its 
permanency.  The  oxyphosphate,  because  of  its  adhesion,  does  sup- 
port frail  walls,  and  therefore  is  peremptorily  required  in  all  such  cases. 
Unlike  gutta-percha,  there  need  be  no  limitation  as  to  the  quantity 
used,  save  that  the  cavity  above  it  must  be  of  a  shape  which  shall  be 
retentive  for  the  metallic  filling  which  is  to  cover  it.     In  these  cases 


62  METHODS  OF  FILLING    TEETH. 

it  is  preferable  to  place  a  portion  of  the  metallic  filling  while  the 
oxyphosphate  is  still  plastic,  for  thus  the  upper  filling  is  practically 
cemented  into  place.     This  process  will  be  described  later. 

As  a  permanent  filling  oxyphosphate  may  be  used  in  cavities  where 
the  more  conductive  properties  of  metal  would  prove  injurious.  It 
also  should  be  employed  in  conspicuous  positions,  as,  for  example,  large 
corners  or  labial  festoon  cavities  in  the  incisor  region,  in  the  mouths 
of  actors  and  actresses,  ministers,  singers,  lecturers,  and  public  speakers 
generally. 

Relative  Values  of  Amalgams. 

Amalgam  is  one  of  the  most  valuable  filling- materials  at  our  dis- 
posal. At  the  same  time  it  is  the  most  abused.  It  is  more  frequently 
chosen  because  of  its  cheapness  than  because  of  its  special  adaptation 
to  a  given  case.  The  result  is  that  it  is  not  properly  manipulated, 
and  is  too  often  allowed  to  remain  without  special  polishing.  Much 
of  the  disrepute  attached  to  amalgam  is  probably  due  to  faulty  filling 
methods,  rather  than  to  any  bad  quality  inherent  in  the  material  itself. 

If  it  is  necessary  to  use  the  dam  for  the  insertion  of  gold,  it  is 
equally  needful  where  amalgam  has  been  decided  upon.  I  do  not 
mean  that  the  dam  must  always  be  employed,  for  I  have  explained 
that  it  is  not  always  a  necessity  even  with  gold,  for  which  it  is  more 
often  used  than  with  other  materials.  It  is  more  exact,  then,  to  say 
that  the  cavity  must  be  kept  as  dry  as  possible,  whether  by  using  the 
dam,  or  by  dependence  upon  the  napkin.  I  think  that  amalgam  in- 
serted without  regard  to  moisture  is  more  likely  to  become  blackened 
than  when  caution  is  used  to  prevent  the  wetting  of  the  material  during 
its  insertion. 

In  mixing  the  alloy  with  the  mercury  I  prefer  adding  the  mercury,  a 
little  at  a  time,  until  a  plastic  mass  is  produced,  rather  than  to  use  too 
great  a  quantity  of  mercury  at  the  outset,  and  then  depend  upon  ex- 
pressing it.  If  mercury,  squeezed  from  amalgam  mixings,  be  pre- 
served in  a  bottle,  and  then  examined,  it  will  be  found  that  it  contains 
a  considerable  proportion  of  metals  which  it  has  absorbed  from  the 
alloy.  Thus  it  would  seem  that  it  has  brought  away  with  it  a  por- 
tion of  that  metal  contained  in  the  alloy  for  which  it  has  the  greatest 
affinity.  The  result  must  be  an  alteration  in  the  proportion  of  metals 
contained  in  the  alloy.  Thus,  if  a  given  alloy  is  used  for  making  an 
amalg'am,  and  one  mixing  is  made  with  just  the  proper  quantity  of 
mercury,  while  a  second  is  prepared  with  an  excess  which  is  removed 
by  pressure,  it  would  seem  natural  to  expect  that  the  two  would  not  act 
similarly  even  in  the  same  mouth.  This  would  explain,  perhaps,  the 
oft-claimed  unreliability  of  an  amalgam,  where  it  will  fail  in  a  tooth 
upon  one  side  of  a  mouth,  and  succeed  admirably  upon  the  other. 


RELATIVE  VALUES  OF  AMALGAMS.  63 

It  is  not  the  amalgam  that  is  unreHable,  but  the  dentist,  who  has  not 
a  definite  method. 

As  it  would  be  a  tedious  process  to  weigh  out  the  alloy  and  mercury 
for  each  mixing,  we  may  resort  to  some  less  accurate  way,  provided 
that  it  accomplishes  the  result  with  reasonable  reliability.  If  the 
attempt  be  made  to  mix  alloys  with  mercury  in  the  hand,  it  will 
usually  result  in  an  excess  of  the  latter.  We  may  better  depend  upon 
the  pestle  and  mortar,  preferably  of  small  size.  Place  in  the  mortar 
the  amount  of  alloy  desired,  and  add  a  little  mercury  ;  stir  vigor- 
ously, and  the  mercury  will  take  up  all  the  alloy  with  which  it  can 
unite.  Add  more,  and  more,  stirring  between  each  addition,  until  the 
mass  is  soaked  with  mercury,  but  perhaps  granular.  If  it  now  be 
turned  into  the  palm  of  the  hand  and  manipulated  vigorously,  the 
friction  produced  will  aid  in  the  amalgamation,  and  a  mass  quite  plastic 
can  be  produced.  This  plasticity  is  not  the  result  of  an  excess  of 
mercury,  for  we  have  seen  that  while  cold,  in  the  mortar,  it  did  not 
reach  such  a  consistency  ;  it  has  been  attained  by  heat  rather,  and 
there  is  no  need  to  squeeze  out  any  mercury,  though,  in  order  to  be 
sure  that  there  is  no  excess,  it  is  as  well  to  squeeze  with  the  finger  and 
thumb.  That  amount  of  pressure  will  not  force  out  any  mercury  if 
too  much  has  not  been  used,  and  if  this  method  of  mixing  be  followed 
it  will  rarely  occur  that  any  excess  will  be  found. 

The  amalgam  is  now  ready  for  use.  To  place  within  a  cavity  as 
large  a  mass  as  can  be  crowded  in,  would  be  as  incorrect  as  to  follow 
the  same  rule  when  using  gold.  Choose  a  piece  which  can  be  dropped 
into  the  cavity  easily,  and  which  under  pressure  will  become  packed 
without  fracturi7ig.  The  homogeneity  is  thus  preserved.  With  a  bit 
of  bibulous  paper  rolled  into  a  small  ball  and  held  in  the  foil- carriers, 
the  amalgam  is  next  pressed,  and  smeared  into  all  the  crooks  and 
corners  of  the  cavity.  Usually  this  first  portion  of  amalgam  may  be 
treated  so  that  it  will  form  a  veneer  covering  all  the  walls.  This 
insures  adaptation.  Piece  after  piece  is  to  be  placed  in  this  way,  and 
if  the  mass  was  properly  mixed  no  excess  will  come  to  the  surface, 
while  under  the  action  of  the  ball  of  paper  a  hard  filling  is  produced 
at  once.  In  large  cavities  a  burnisher  may  be  used  over  the  paper, 
to  exert  more  force  than  can  be  attained  with  the  foil-carriers. 

When  the  cavity  is  filled,  the  next  step  is  to  follow  a  process  which 
apparently  prevents  shrinkage.  Indeed,  it  will  do  movQ,  for  it  zaill 
preserve  a  handsome  "  white"  color  for  years.  Alloys  which  contain  a 
large  proportion  of  gold  have  not  proven  successful.  Nevertheless  it  is 
gold  upon  which  we  must  depend  for  this  most  desirable  improvement 
in  amalgam  fillings.  Take  gold  foil  No.  3  (No.  4  may  be  used,  but 
the  thinner  grade  is  preferable),  and  tear  it  into  small  pieces  without 
folding  or  rolling.     When  the  tooth  has  been  filled  with  the  amalgam. 


64  METHODS  OF  FILLING   TEETH. 

place  upon  it  a  piece  of  this  thin  foil.  Then  with  a  warm,  smooth 
burnisher  gently  stroke  the  gold  till  the  mercury  in  the  amalgam 
absorbs  it.  This  is  not  the  old  scheme  of  using  tin  to  extract  mercury 
from  an  amalgam  filling.  In  that  method  the  tin  does  not  enter  the 
filling,  but  acts  in  removing  the  mercury,  as  a  sponge  does  in  sopping 
up  water  from  the  floor.  The  gold,  on  the  contrary,  -must  be  forced 
into  the  filling,  so  that  it  changes  the  surface  into  an  amalgam  of  which 
gold  is  a  component  part.  Gold  is  to  be  manipulated  in  this  way, 
upon  and  into  the  amalgam,  until  it  will  no  longer  be  absorbed.  This 
can  be  continued  until  the  surface  of  the  filling  is  quite  hard,  and  even 
golden  in  color.  This  color  will  not  be  retained  after  the  crystalliza- 
tion, but  the  filling  when  polished  at  a  subsequent  sitting  will  be  found 
of  fine  texture,  and  will  receive  a  mirror-like  finish. 

Where  a  large  contour  is  to  be  made,  involving  say  two  or  three 
cusps  of  a  molar,  an  excess  of  amalgam  is  to  be  used,  and  then  when 
the  gold  is  applied  a  density  will  soon  be  reached  which  will  allow  the 
operator  to  carve  up  cusps,  by  removing  the  excess  of  material  and 
forming  sulci,  after  which  more  gold  is  to  be  burnished  into  the  filling 
until  the  surface  is  apparently  set.  A  large  filling  of  this  character 
may  be  dismissed  with  little  fear  of  seeing  it  crushed  into  shapelessness 
at  a  subsequent  visit.  Moreover,  it  is  much  easier  to  trim  up  a  contour 
while  the  material  is  thus  semi-plastic  than  to  be  obliged  to  defer  this 
for  another  day.  It  thus  becomes  apparent  that  if  the  best  results  of 
amalgam  are  to  be  reached  by  burnishing  gold  into  its  surface,  we 
cannot  hope  for  the  most  perfect  fillings  when  we  use  a  matrix,  and  do 
not  obtain  a  separation  of  the  teeth  in  advance  of  the  filling.  This  is 
only  one  more  argument  against  the  matrix,  which  I  have  said  is  useful 
only  with  amalgam,  whereas  now  we  see  that  even  with  this  material 
it  has  its  disadvantages,  since  it  prevents  the  burnishing  of  gold  along 
the  approximal  surface. 

I  now  approach  the  important  subject  of  where  to  use  amalgams. 
There  is  little  doubt  that  many  cavities  can  be  well  filled  with  amal- 
gam in  localities  where  perfect  gold  fillings  would  be  impossible,  yet, 
I  am  not  a  believer  in  the  material  to  such  an  extent  that  I  would 
advocate  the  too  common  practice  of  deciding  that  any  cavity  which 
is  in  an  inconspicuous  location  may  be  as  well  filled  with  amalgam  as 
with  gold.  Too  many  patients  have  been  so  educated  by  contact 
with  dentists,  that  they  will  say,  "  It  will  not  be  seen,  doctor  ; 
therefore  fill  it  with  amalgam."  This  is  an  error,  though  the  con- 
verse is  true, — i.e.,  "It  will  be  seen;  therefore  do  not  fill  it  with 
amalgam, ' '  though  even  to  this  last  rule  there  must  be  an  occasional 
exception,  as  far  back  as  the  bicuspid  region.  I  think  it  would  be  a 
wise  rule  which  would  rigidly  exclude  amalgam  from  incisors  and 
cuspids,  and  from  bicuspids  as  often  as  possible. 


CHOICE  OF  FILLING-MA  TERIALS.  65 

Cavities  in  the  crowns  of  molars,  though  out  of  sight,  should  be 
filled  with  gold,  the  rule  being  relaxed  only  as  the  cavity  becomes 
larger.  If  a  cavity  be  small,  and  therefore  of  that  class  which  may 
be  safely  filled  with  anything  and  be  preserved  as  long  as  the  duration 
of  the  material,  //  is  the  very  place  for  gold,  because  gold  is  the  most 
durable  and  reliable  of  all  materials.  A  phosphate  or  a  gutta-percha 
filling  will  stop  caries,  but  these  must  be  considered  temporary,  and 
amalgam  preferred  to  either.  For  a  similar  reason  gold  must  be  chosen 
instead  of  amalgam.  As  we  come  to  consider  cavities  of  larger  size 
the  rule  becomes  less  binding,  till  at  last  the  point  is  reached  where 
it  becomes  a  decidedly  difficult  question  to  determine  which  material 
must  have  preference.  One  way  of  reaching  a  decision  is  to  consider 
that  the  seemingly  frail  walls  will  still  support  a  gold  filling,  because 
of  the  fact  that  the  pulp  is  still  living.  In  a  similar  cavity,  where  the 
pulp  has  been  removed,  it  might  be  safer  to  depend  upon  amalgam. 
After  this  point  has  been  passed,  and  the  cavities  presented  for  con- 
sideration are  of  great  size,  amalgam  should  be  the  first  choice,  and 
gold  used  only  where  everything  combines  to  make  a  perfect  operation 
possible.  Thus,  if  the  patient  is  of  good  health,  with  strong  nervous 
stamina,  and  willing  to  endure  fatigue,  it  becomes  possible  to  place  a 
large  gold  filling,  with  the  hope  that  the  last  third  may  be  as  well  con- 
densed as  the  first.  Too  often  operator  and  patient  undertake  that 
which,  because  of  the  tedlousness,  becomes  so  great  a  tax,  that  in  the 
end  the  work  is  hastily  finished,  and  thus  improperly  completed. 
Either  the  gold  is  not  packed  with  sufficient  force  to  produce  a  resistant 
density  of  surface,  or  there  is  not  sufficient  material  used  to  allow  of 
proper  contour  or  occlusion.  Again,  given  favorable  circumstances 
as  to  health  and  strength  of  patient,  the  welfare  of  the  tooth  itself 
must  be  considered  ;  that  is,  whether  the  placing  of  a  gold  filling 
would  become  a  hazardous  operation.  Where  a  recent  attack  of  perice- 
mentitis has  been  aborted,  it  might  be  attended  with  unfortunate  results 
to  work  upon  the  tooth  for  a  period  long  enough  to  fill  it  with  gold. 

Thus,  as  I  have  said,  as  the  cavity  increases  in  size,  the  demand 
for  amalgam  is  correlatively  increased,  though  a  gold  filling  properly 
made  is  always  preferable. 

An  important-place  for  amalgam  is  where  the  cavity-border  is  below 
the  gum-line.  No  filling  will  succeed  here  unless  the  finished  surface 
along  the  gingival  border  can  be  made  scrupulously  smooth.  There 
are  many  such  cavities  which  should  be  filled  with  amalgam  rather 
than  with  gold,  solely  for  the  reason  that  the  amalgam  may  be  made 
smooth  more  readily  than  gold.  Many  such  may  be  filled  with  gold  by 
a  dentist  dexterous  in  placing  the  dam,  and  yet  the  filling  after  comple- 
tion may  defy  the  efforts  of  even  a  skillful  operator  to  properly  polish 
along  the  gingival  border.     Approximal  trimmers  will  do  much,  but 

5 


66  METHODS  OF  FILLING   TEETH. 

at  best  they  leave  a  filed  surface.  Would  we  deliver  a  gold  plate 
which  showed  file-marks?  If  not,  why  should  we  leave  a  filling  in 
such  a  condition?  It  must  be  remembered  that  the  cavity-border 
up  under  the  gum-line  may  be  accessible  while  the  cavity  is  empty, 
but  the  placing  of  a  properly  contoured  filling  must  make  it  more 
than  ever  inaccessible,  so  that  the  gingival  border  may  become  utterly 
concealed.  An  amalgam  filling  may  be  made  flush  at  this  important 
point  while  it  is  yet  plastic,  and  the  utmost  care  should  be  used  to 
make  it  so  at  the  time  of  filling,  for  if  a  gold  filling  is  difficult  to  polish, 
an  amalgam  filling,  after  hardening,  is  even  more  so. 

It  is  claimed  by  some  that  it  is  good  practice  to  build  with  amalgam 
from  one  approximal  cavity  across  into  another  in  the  adjacent  tooth. 
This  seems  to  be  of  doubtful  merit,  and  rather  to  be  condemned  than 
advocated.  However  that  may  be,  it  is  generally  admitted  that  a 
filling  in  an  approximal  cavity  must  not  jut  out  and  press  upon  the 
gum-tissue.  Moreover,  care  must  be  taken  not  to  force  particles  of 
amalgam  under  the  gum,  which  by  being  left  may  bring  about  a 
condition  of  ulceration.  Where  the  dam  cannot  be  placed,  I  have 
found  a  means  of  accomplishing  this  very  nicely.  Take  a  bit  of 
bibulous  paper  and  make  a  tight  rope  of  it,  thick  enough  to  just  pass 
between  the  teeth.  This  rope  is  to  be  laid  against  the  gum  and 
pressed  up  beyond  the  cavity-margin,  which  can  be  done  more  often 
than  would  seem  possible  to  those  who  have  not  tried  it.  This 
effectually  prevents  any  material  from  passing  beyond  the  gum-line, 
and  when  drawn  out  after  the  tooth  is  filled  leaves  a  well-defined  space, 
wherein  the  burnishers  may  be  used  for  properly  shaping  the  filling 
along  the  gingival  margin.  Nevertheless,  in  spite  of  the  efficacy  of 
this,  it  is  usually  advisable  to  thoroughly  syringe  the  parts  with  warm 
water,  using  a  syringe  which  will  throw  a  stream  with  considerable 
force,  placing  the  point  at  the  gum-line,  so  that  the  water  passes  be- 
tween the  teeth  and  washes  out  any  debris. 

In  spite  of  the  fact  that  I  have  here  advised  the  use  of  amalgam 
in  cases  where  the  gingival  margin  is  above  the  gum-line,  yet  I 
would  distinctly  deprecate  the  use  of  this  material  for  patching  gold 
fillings  which  have  failed  in  that  locality.  I  think  it  would  be  better 
to  remove  the  leaky  filling  entirely  before  refilling,  for  certainly  I  have 
seen  numerous  successful  cases  where  the  amalgam  had  been  placed 
along  the  gingival  border  first,  and  a  completion  of  the  filling  made 
with  gold  subsequently.  Let  me  not  be  misunderstood,  therefore. 
It  is  not  the  use  of  amalgam  in  connection  with  gold  that  I  deprecate, 
but  only  its  use  as  2.patch  near  the  gum-margin.  This  brings  us  to  the 
consideration  of  amalgam  in  combination  with  other  materials.  It  has 
been  successfully  used  with  gold  in  two  ways.  The  most  widely 
known  is  where  the  amalgam  is  placed  along  that  part  of  a  cavity 


MANIPULA  TION  OF  AMAL  GAMS.  67 

vvhich,  being  below  the  gum-line,  is  impossible  to  keep  dry.  This  is 
filled  with  amalgam  until  the  dam  can  be  placed  so  that  the  rest  of 
the  cavity  may  be  dried  thoroughly.  The  amalgam  is  allowed  to 
set,  and  at  a  subsequent  sitting  a  portion  of  it  removed,  leaving  as 
little  within  the  cavity  as  possible,  without  risking  the  slipping  of 
the  dam.  The  gold  is  then  placed,  being  partly  anchored  into  under- 
cuts made  in  the  amalgam.  This  is  often  advisable.  Especial  cases 
arise  where  a  large  portion  of  an  anterior  approximal  surface  of  a 
bicuspid  has  been  lost  by  caries.  Restoration  with  amalgam  alone 
would  be  unsightly,  and  with  gold  alone  impossible.  The  amalgam 
may  be  placed  along  the  gingival  fourth  or  fifth  of  the  cavity,  and 
covered  with  gutta-percha,  till  the  next  sitting,  when  it  will  be  found 
that  the  dam  may  be  used  and  the  gold  packed  into  the  remainder 
of  the  cavity.     When  all  is  done,  nothing  shows  but  the  gold. 

The  second  method  is  to  pack  the  gold  upon  the  fresh  amalgam. 
To  accomplish  this  a  matrix  is  required,  and  the  plastic  golds  are 
preferable  to  form  the  contact  with  the  amalgam.  This  kind  of  gold 
may  be  readily  packed  against  the  amalgam,  and  will  soon  assert 
itself  by  overcoming  the  efforts  at  amalgamation  to  such  an  extent 
that  the  filling  may  be  completed  with  cohesive  foil  at  the  same  sitting. 
A  filling  of  this  nature  made  in  a  glass  tube  an  inch  long,  one-half  of 
each  metal,  has  been  so  successfully  made  that  the  resulting  rod  when 
removed  from  the  glass  showed  a  perfect  union,  with  great  strength, 
between  the  gold  and  the  amalgam.  The  objection  to  this,  in  my  mind, 
is  that  the  matrix  must  be  used. 

It  will  frequently  occur  that  a  cavity  is  so  shallow  and  of  such  poor 
shape  for  retention  that  it  is  questionable  whether  an  amalgam  filling 
would  be  retained.  Here  we  may  frequently  depend  upon  a  method 
which  is  exceedingly  useful  with  gold  also.  Mix  oxyphosphate  to  a 
sticky  consistency,  and  smear  some  upon  the  walls  of  the  cavity,  imme- 
diately adding  some  amalgam.  Allow  the  phosphate  to  set  thoroughly, 
and  the  amalgam  is  practically  cemented  to  place.  The  filling  is  then 
continued  by  adding  more  amalgam,  and  will  be  more  Hkely  to  remain 
in  place  because  of  the  underlying  phosphate.  Care  must  be  taken, 
before  adding  the  second  batch,  that  no  phosphate  be  left  overlapping 
any  of  the  margins,  as  that  would  leave  a  weak  point. 

In  a  similar  way,  in  deep  crown  cavities,  we  may  depend  upon  the 
phosphate,  not  only  as  a  protection  to  the  nearly  approached  pulp  but 
as  an  additional  retentive  precaution,  provided  we  pack  the  amalgam 
before  the  phosphate  sets,  instead  of  waiting  till  afterward,  as  is  the  usual 
custom. 

The  mixing  of  an  amalgam  with  a  phosphate  I  have  never  tried,  and 
can  see  no  advantage  in.  The  mixing  of  the  alloy  with  the  phos- 
phate, however,  is  totally  different,   and  in    many  cases   a   practice 


68  METHODS  OF  FILLING  TEETH. 

deserving  of  much  praise.  The  dry  phosphate  powder  is  mixed  with 
the  fine  fiHngs  of  an  alloy,  and  afterward  used  in  connection  with  the 
liquid,  exactly  as  plain  oxyphosphate  fillings  are  made.  The  presence 
of  the  metal  interferes  with  the  mixing  only  a  little,  and  the  usual 
putty-like  consistency  may  be  attained.  A  filling  of  this  kind  is  to  be 
placed  and  allowed  to  set  two  or  three  days.  It  may  then  be  polished 
by  using  a  smooth  stone  in  the  engine. 

I  have  seen  these  fillings  advocated  in  all  positions,  but  I  consider 
them  more  useful  in  masticating  surfaces  than  elsewhere.  The  dis- 
advantage of  any  cement  filling  is  that  it  slowly  dissolves  out.  By 
adding  the  alloy  we  have  an  ordinary  phosphate  filling  which  holds  a 
number  of  particles  of  metal  in  close  contiguity.  As  with  any  other 
phosphate,  the  material  itself  gradually  wears  away.  As  the  metal 
does  not  dissolve,  it  is  plain  that  the  surface  becomes  roughened,  as 
the  metal  filings  become  more  and  more  exposed.  For  this  reason  it 
is  not  wise  to  use  the  method  in  approximal  surfaces,  since  the 
roughened  filling  will  invite  decay.  But  in  the  masticating  surface  a 
totally  different  result  obtains.  As  fast  as  the  metal  filings  are  exposed, 
they  are  flattened  down  by  attrition,  till  at  length  the  whole  surface  is 
metallic,  and  can  be  burnished  just  as  an  amalgam  filling  may  be. 
After  this,  the  phosphate  being  thoroughly  protected  by  this  metallic 
veneer,  there  is  no  further  waste. 

These  fillings  are  especially  good  in  temporary  teeth,  though  I 
sometimes  use  them  in  adult  mouths.  When  I  do,  it  is  because  of  their 
low  conductive  power.  Where  a  cavity  is  very  sensitive,  and  it  is 
deemed  advisable  to  place  a  filling  temporarily  until  such  time  as  when, 
the  sensitiveness  having  been  controlled,  gold  may  be  inserted,  this 
combination  of  an  alloy  mixed  with  a  phosphate  is  excellent. 

Copper  amalgam  has  been  so  much  in  vogue  in  recent  years  that  I 
can  scarcely  pass  the  subject  without  alluding  to  it.  I  have  only  a 
{q.w  facts  to  mention,  and  will  leave  deductions  to  the  reader. 

When  copper  amalgam  was  introduced  into  this  country  as  a  sub- 
stitute for  the  ordinary  alloys,  its  advocates  claimed  that  aside  from 
not  having  many  disadvantages  attributable  to  ordinary  amalgams,  it 
possessed  a  therapeutic  quality,  in  that  no  carious  action  could  recur 
in  its  vicinity.  Practice  has  not  szibstantiated  this  claim.  Copper 
am,alga7n  fillings,  from  the  hands  of  practitioners  known  to  me  clinically 
as  expert  operators,  have  coTne  under  viy  observation  leaki?ig  badly. 

When  a  copper  amalgam  filling  becomes  thoroughly  blackened,  is 
then  well  polished,  and  finally  assumes  a  bright  ebony-like  surface,  it 
seems  to  be  the  most  admirable  tooth-saver  known.  This  is  a  success. 
When,  on  the  contrary,  it  does  not  become  black,  but  remains  a  dull, 
lusterless  gray,  it  will  be  found  readily  removable  with  an  excavator, 
and  will  waste  away  as  surely  as  a  phosphate  filling.     This  is  a  failure. 


GOLD  AS  A  FILLING-MA  TERIAL.  6g 

Were  it  possible  to  determine  in  what  mouths,  and  under  what  con- 
ditions, these  two  results  could  be  prognosticated,  we  would  be  enabled 
to  give  copper  amalgam  a  prominent  place  in  our  cabinets.  But 
when  it  is  known  what  many  have  observed,  first,  that  fillings 
which  appear  successful  for  months  will  suddenly  deteriorate  into  a 
condition  similar  to  that  described  as  a  failure;  second,  that  fillings 
may  be  successful,  and  unsuccessful,  in  the  same  mouth  at  the  same 
time  ;  and  third,  that  two  fillings  have  been  made  at  the  same  sitting, 
from  the  same  material,  placed  in  the  same  tooth,  both  in  the  masti- 
cating surface,  and  that  one  of  these  has  proven  successful  while  the 
other  has  utterly  failed,  we  are  compelled  to  admit  that  at  present 
copper  amalgam  is  utterly  unreliable.  It  has  been  suggested  that  the 
failures  are  attributable  to  the  manner  of  manufacturing  the  material. 
This  may  be  so.  But  until  the  true  secret  of  manufacture  shall  have 
been  discovered,  copper  amalgam  cannot  be  recommended. 

Gold  as  a  Filling-Material. 

Gold  is  pre-eminently  the  best  material  with  which  to  fill  teeth.  It 
has  the  great  disadvantage  of  being  a  good  conductor  of  heat,  and  it 
unfortunately  requires  considerable  time  for  its  proper  insertion,  in 
addition  to  which  it  lacks  some  of  the  good  qualities  of  other  materials  ; 
but  nevertheless  it  can  be  stated  positively  that  the  main  reliance  for 
the  salvation  of  teeth  which  have  decayed  must  be  upon  gold. 

It  then  becomes  of  the  gravest  importance  for  a  dentist  to  thoroughly 
understand  this  material  and  its  manipulation,  and'after  acquiring  the 
requisite  skill,  to  be  conscientious  in  his  application  thereof 

It  is  furnished  to  us  mainly  of  two  kinds,  cohesive  and  non-cohesive, 
and  in  three  forms,  viz,  foil,  including  cylinders  and  blocks,  rolled  or 
heavy  foil,  and  the  various  kinds  of  plastic  gold. 

In  using  gold,  the  dividing  line  is  where  we  decide  to  depend  upon 
non-cohesive  or  cohesive  gold.  Non-cohesive  gold  was  used  by  the 
earlier  dentists  exclusively,  because  the  dependence  upon  the  cohesive 
property  of  the  metal  is  comparatively  recent.  Since  the  adoption  of 
cohesive  gold,  the  older  methods  have  fallen  into  such  disuse  that  it  is 
safe  to  say  that  only  a  small  percentage  of  dentists  still  follow  them, 
while  a  very  large  proportion  of  the  younger  men  have  never  even 
essayed  them.  The  question  then  arises,  ' '  Is  there  any  advantage 
in  non-cohesive  gold  which  is  sufficiently  important  to  make  it  deserve 
a  place  in  ofhce  practice?"  If  there  is,  I  am  ignorant  of  it.  In  mak- 
ing this  statement,  I  am  aware  that  I  will  be  criticised,  but  my  position 
is  just  this  :  In  my  own  experience  I  have  never  discovered  any  special 
use  for  non-cohesive  gold.  I  have  never  been  able  to  appreciate  the 
advantage  of  having  my  gold  so  that  the  different  particles  would  not 
cohere  under  pressure,  nor  have  I  been  able  to  see  the  disadvantage 


70  METHODS  OF  FILLING  TEETH. 

of  having  them  cohere.  I  have  frequently  met  prominent  men  who 
have  admitted  using  non-cohesive  gold.  I  have  invariably  asked  these 
men  why  they  ever  prefer  it  to  cohesive  gold,  and  the  replies  have 
always  been  either  evasive  or  unsatisfactory.  The  best  answer  ever 
offered  to  me  is  that  non-cohesive  gold  may  be  used  where  a  cohesive 
gold  filling  would  be  an  impossibility,  as  for  example,  in  the  buccal 
surface  of  a  molar  in  the  lower  jaw,  where  the  cavity  extends  so  far 
below  the  gum-margin  that  the  dam  cannot  be  employed.  It  is 
claimed  that  a  good  gold  filling  can  be  made  in  such  a  situation  if 
non-cohesive  gold  be  used.  I  believe  that  this  is  possible,  but  I  also 
believe  that  it  is  possible  only  in  the  hands  of  a  limited  few  who  have 
attained  to  extreme  skill  in  the  manipulation  of  the  non-cohesive 
golds.  I  think  that  as  a  practice  for  the  many  a  large  percentage  of 
failures  would  be  the  result,  while  the  same  men  could  produce  admir- 
able and  sufficiently  permanent  results  with  other  material  than  gold. 

A  use  which  I  was  taught  to  make  of  non-cohesive  gold  is  to  place 
it  against  the  walls  of  cavities,  finishing  with  cohesive  foil  ;  the  idea 
being  that  non-cohesive  gold  can  be  better  made  to  adapt  itself  to  the 
walls,  and  that  thus  a  more  nearly  water-tight  filling  will  be  produced. 
This  I  think  must  be  condemned,  especially  where  by  so  doing  we 
would  occupy,  with  non-cohesive  gold,  that  part  of  the  cavity  upon 
whose  shape  we  depend  for  the  retention  of  the  whole  mass  of  the 
fiUing.  While  there  will  be  some  cohesion  between  the  underlying 
layer  and  the  superincumbent  portion  which  is  made  with  cohesive 
gold,  I  am  certaia  that  a  stronger  filling  can  be  made  where  cohesive 
gold  is  used  throughout.  I  have  removed  so  many  fillings,  taicing 
out  first  a  solid  piece,  and  then  picking  out  the  remainder  in  crumbs, 
that  I  believe  the  practice  has  been  relied  upon  by  many.  My  removal 
of  such  fillings  has  usually  been  because  of  discolored  margins,  show- 
ing where  caries  had  crept  in  and  was  undermining  the  fillings. 

My  opinion,  then,  of  non-cohesive  gold  is  that  in  practice  we  have 
so  little,  if  any,  need  for  it,  that  the  dentist  may  discard  it  almost  in 
toto.  In  the  colleges,  however,  its  management  should  be  taught,  for 
the  student  who  learns  to  fill  with  non-cohesive  foil  will  have  acquired 
a  degree  of  manual  dexterity  which  will  quickly  make  him  expert  in 
the  use  of  cohesive  gold.  Too  many  have  neglected  to  learn  in  this 
way,  and  the  cohesiveness  of  gold  has  e^iabled  many  inexpert  men  to 
practice  deyitistry,  palming  off  upon  patients  fillings  which  may  look 
bright  and  smooth  to  the  inexperienced  eye,  but  which  in  a  few  months 
become  rough,  in  which  condition  they  are  a  menace  to  the  safety  of  the 
teeth. 

Of  the  manipulation  of  cohesive  gold  much  could  be  written.  It 
is  my  purpose  here  only  to  point  out  the  more  important  facts,  and  if 
possible  to  draw  attention  to  a  few  points  of  faulty  working,  upon 


GOLD  AS  A  FILLING-MATERIAL.  Jl 

which  I  think  many  failures  depend.  I  like  to  have  all  three  kinds 
of  cohesive  gold  in  the  office.  A  cavity  may  be  filled  with  either, 
exclusively,  and  in  many  smaller  cavities  it  is  wise  to  do  this.  There 
are  many  other  cases  where  the  employment  of  two  and  sometimes 
of  three  kinds  of  gold  is  expedient. 

Of  the  plastic  golds,  I  have  had  the  most  experience  with  Watts' s 
crystal.  This  is  a  form  of  gold  much  praised  by  many,  and  much 
condemned  by  others.  Its  strongest  advocates  undoubtedly  use  it 
too  frequently,  and  place  too  much  dependence  upon  it,  while  those 
who  condemn  it  utterly  are  sim.ply  ignorant  of  its  virtues.  They  have 
probably  endeavored  to  use  it  as  they  do  other  plastics,  forgetting 
that  it  is  a  metal.  Its  chief  virtues  are  :  first,  its  great  cohesiveness, 
no  gold  having  more,  if  any  has  as  much  ;  second,  the  smau  amount 
of  force  necessary  for  condensing  it ;  and  third,  the  fact  that  it  will 
remain  where  it  is  placed,  having  no  tendency  to  ball  up,  and  roll 
about  in  a  cavity. 

Its  first  advantage,  cohesiveness,  makes  it  especially  useful  in  many 
instances,  of  which  I  will  enumerate  a  few.  It  has  occurred  to  many 
that  while  inserting  a  large  filling,  leakage  has  made  some  portion  of 
the  surface  of  the  partly-made  filling  non-cohesive.  The  effort  to  add 
another  pellet  of  foil  is  vain.  If  the  surface  be  touched  with  alcohol 
and  then  dried  with  hot  air,  crystal  gold  will  adhere,  provided  it  is 
used  ill  small  pieces.  I  have  even  removed  the  dam,  where  a  large 
gold  filling  was  but  half  finished,  and  continued  the  operation  at  a 
subsequent  sitting,  the  gold  meanwhile  having  been  protected  by 
gutta-percha,  though  of  course  this  did  not  keep  it  dry.  Such  a  pro- 
cedure should  not  be  adopted  unless  the  remainder  of  the  cavity  still 
presents  a  retentive  shape.  Thus  the  adhesion  of  the  crystal  gold 
becomes  more  a  matter  of  convenience  than  of  necessity  in  such  cases. 
Where  a  fillingbecomes  wet  before  completion,  it  being  in  an  exposed 
position,  as  the  corner  of  a  central  incisor,  if  it  be  dried  with  alcohol 
and  hot  air,  as  before  advised,  and  then  a  clean  rose  bur  be  used  to 
freshen  the  whole  surface  of  the  metal,  crystal  gold  may  be  made  to 
unite  firmly  with  it,  and  the  filling  may  then  be  safely  completed. 

If,  while  filling,  a  bit  of  the  edge  of  a  cavity  crumbles  away  by  acci- 
dent, or  when  finishing  it  is  seen  that  there  is  a  slight  imperfection 
along  the  border,  crystal  gold  is  invaluable.  The  tiniest  burs  may  be 
used  to  cut  a  groove  or  pit,  and  this  may  be  more  perfectly  filled  with 
crystal  gold  than  any  other,  because  of  its  cohesiveness,  and  more 
particularly  because  it  can  be  torn  into  smaller  bits  without  losing  its 
pliability. 

A  third  use  is  where  a  portion  of  a  cavity  which  is  very  inaccessible 
requires  the  use  of  the  mouth-mirror.  Such  a  place  might  occur 
where,  in  an  approximal  cavity  in  an  incisor,  the  palatal  depredation 


72  METHODS  OF  FILLING  TEETH. 

has  been  great,  and  an  examination  of  this  palatal  portion  after  the 
filling  is  nearly  completed  shows  that  it  is  not  full  enqugh.  Crystal 
gold  can  be  built  on  here  more  readily  than  any  other. 

The  second  good  quality,  its  plasticity,  makes  crystal  gold  espe- 
cially useful  over  nearly-approached  pulps .  It  is  frequently  instructive 
for  a  dentist  to  have  his  own  teeth  filled.  He  then  discovers,  much 
to  his  surprise  perhaps,  that  certain  methods  produce  pain,  which,  as 
the  dentist,  he  may  have  thought  to  be  painless,  or  where  patients 
have  complained,  he  may  have  attributed  the  cause  erroneously.  I 
have  myself  been  astonished  to  find  that  the  mallet  will  cause  excru- 
ciating pain  over  a  particular  spot ;  pain,  too,  of  a  character  which 
showed  that  the  pulp  itself  was  disturbed.  It  is  my  opinion  that 
where  a  pulp  is  nearly  approached,  that  point  of  the  dentine  which  is 
thinnest,  becoming  more  resilient,  yields  slightly  under  the  force  of  the 
mallet,  thus  producing  pressure,  which  shocks  the  pulp.  Therefore, 
when  a  patient  complains  of  a  distinct  pain  from  the  mallet  at  a  specified 
point,  and  at  that  point  only,  or  more  than  elsewhere,  I  now  attribute 
the  disturbance  to  the  above- described  cause,  and  continue  the  filling 
with  crystal  gold,  using  hand-pressure  until,  having  built  a  sufficient 
thickness  of  metal  over  the  thin  portion  of  dentine,  I  find  that  the 
pulp  no  longer  responds  painfully  to  the  mallet-stroke.  For  similar 
reasons  small  cavities  may  best  be  filled  with  crystal  gold,  using  hand- 
pressure,  whenever  the  tooth  is  sore  from  wedging.  Still,  except  in 
the  smallest  cavities,  I  should  prefer  to  make  the  extreme  outer  sur- 
face of  heavy  foil,  as  will  be  described. 

Another  most  important  usefulness  of  crystal  gold  is  that  its  plas- 
ticity allows  the  operator  to  work  with  less  danger  of  fracture  along 
weak  walls  or  in  deep  undercuts.  A  more  resistant  form  of  gold, 
acting  as  a  wedge  in  such  an  undercut,  may  crack  or  even  break  the 
enamel.  I  have  seen  a  whole  corner  forced  off"  with  a  corkscrew  plug- 
ger,  which  was  being  used  to  drive  a  pellet  ahead  of  it.  I  think  it 
could  have  been  well  filled  and  preserved  by  the  use  of  crystal  gold. 
This  accident  occurred  at  a  clinic,  and  caused  the  operator  much 
chagrin,  but  from  an  educational,  standpoint  it  furnished  a  better 
object-lesson  than  if  it  had  not  happened. 

The  third  quality,  that  of  not  balling  up,  brings  me  to  a  description 
of  the  right  and  of  the  wrong  way  to  use  crystal  gold.  While  it  is  true 
that^t  will  not  ball  up  if  properly  used,  it  is  also  true  that  it  will  so 
act  in  unskillful  hands.  The  great  danger  with  this  material  is  the 
temptation  to  use  too  large  pieces.  The  inexperienced  may  think 
that,  being  plastic,  it  may  be  crowded  into  a  large  cavity  and  then 
condensed  afterward.  I  have  seen  this  method  advocated  at  a  college 
clinic  by  one  of  the  instructors.  It  is  a  mistake.  In  the  majority  of 
such  cases,  when  the  mass  is  condensed,  it  will  be  found  that  it  can  be 


GOLD  AS  A  FILLING-MATERIAL.  73 

-mo^•ed  to  and  fro  within  the  cavity.  Whe^iever  this  occurs,  with  ayiy 
kind  of  gold,  the  o)ily  correct  procedure  is  to  remove  the  whole  a7id  beo-in 
again.  To  attempt  to  hold  it  in  place,  until  wedged  by  what  is  placed 
above  it,  is  to  decei\'e  one's  self  and  defraud  the  patient.  The  mass 
may  be  thus  fastened  so  that  it  will  not  move,  but  the  space  between 
it  and  the  walls,  which  must  have  existed  since  inotion  was  possible, 
will  not  have  been  eradicated.  I  cannot  use  language  too  positive  in 
recommending  small  pieces  of  this  or  any  other  kind  of  gold.  / 
never  place  any  bit  ofgoldwithiyi  a  cavity  which  cajinot  pass  the  orifice 
without  toicching  the  edges.  I  frequently  use  pieces  even  smaller  than 
would  be  thus  indicated.  The  rule  is  as  binding  with  a  plastic  gold 
as  with  any  other. 

Another  method  of  manipulation  which  I  think  is  a  grave  error  is 
to  use  a  foot-plugger  with  crystal  gold.  A  foot-plugger  has  a  distinct 
usefulness,  but  it  is  an  instrument  which  produces  many  poor  fillings, 
simply  because  used  in  wrong  places.  I  use  small  points  for  all  kinds 
of  gold,  and  equally  so  for  crystal.  Suppose  that  a  mass  of  crystal 
o^old  be  placed  against  the  filling  within  the  cavity,  just  as  the  gingival 
margin  is  to  be  covered.  I  should  condense  it  with  small  points,  thus 
uniting  it  perfectly  with  the  gold  already  placed,  and  gradually  ap- 
proaching the  borders.  Then  I  should  exchange  for  a  foot-plugger, 
and  go  over  the  surface,  flattening  out  hills,  and  especially  perfecting 
the  impaction  against  the  border,  finally  chiseling  off  with  this  same 
plugger  all  the  excess  which  projected  beyond  and  over  the  edge.  To 
sum  up,  then,  I  should  depend  upon  crystal  gold  mainly  for  covering 
the  walls  of  cavities,  and  for  such  other  places  as  I  have  indicated.  I 
should  not  use  it  much  for  contour  work,  or  allow  it  to  reach  broad 
masticating  surfaces.  Care  should  be  used  to  see  that  it  is  not  partly 
condensed  before  it  is  inserted  in  the  cavity.  It  should  therefore  never 
be  held  in  the  fingers.  A  good  method  is  to  make  a  gold  wire  loop, 
or  staple,  and  with  this  pin  the  cake  of  gold  to  the  wooden  box  in 
which  it  is  sold.  Small  bits  may  be  torn  off  with  the  foil-carrier  as 
needed,  without  danger  of  compressing  the  mass. 

Passing  now  to  foil,  I  have  to  consider  briefly  the  various  forms 
in  which  it  is  supplied.  In  the  first  place,  there  is  the  condition 
of  the  surface.  We  find  this  either  bright  as  though  burnished,  or 
rough,  appearing  as  if  "frosted."  This  style  of  gold  has  various 
names,  depending  upon  the  maker.  I  do  not  remember  any  special 
advantage  that  has  been  claimed  for  it,  and  it  is  probably  manufac- 
tured to  supply  a  demand  created  by  a  habit,  rather  than  by  reason. 
On  the  contrary,  my  own  experience  with  it  would  condemn  it.  It 
is  less  cohesive  than  the  plain,  and  this  is  seen  to  be  natural  upon 
a  moment's  consideration.  The  adherence  of  one  thing  to  another 
may  be  produced  at  any  time  by  effecting  absolute  contact.     Glass, 


74  METHODS  OF  FILLING   TEETH. 

which  we  would  not  count  as  possessing  the  property  of  adhesive- 
ness, will  develop  the  property  if  two  smooth  pieces  be  wet  and  laid 
one  upon  the  other.  There  is  nothing  sticky  about  the  water,  and 
its  action  is  simply  in  completing  the  contact.  Therefore  smooth 
gold  should  be  more  cohesive  than  rough.  I  have  been  told  that 
this  frosted  gold  is  more  easily  worked,  that  it  is  softer.  That  is  ad- 
mitting that  it  is  less  cohesive,  since  the  words  "soft"  and  "  non-co- 
hesive" have  become  synonymous  when  applied  to  gold.  Moreover, 
this  very  softness  is  a  disadvantage,  since  it  renders  the  material 
crumbly,  another  property  of  non-cohesive  gold  fillings.  If  cohesive 
gold  is  to  be  used,  it  should  be  as  cohesive  as  it  can  be  obtained,  and 
while  it  should  he  pliable,  we  need  toughness  in  preference  to  softness. 

Secondly,  as  to  the  form  in  which  to  use  cohesive  gold.  Of  course 
the  packing  of  a  continuous  rope  into  a  cavity  is  not  to  be  thought  of. 
An  advantage  with  non-cohesive  gold,  it  becomes  a  mistake  with  co- 
hesive foil.  The  whole  idea  of  such  a  procedure  is  to  produce  a  filling 
made  of  as  few  pieces  as  possible.  This  is  no  longer  needed  when  we 
can  obtain  a  cohesion  between  the  particles.  It  is  therefore  probable 
that  the  axiom  should  be  reversed,  so  as  to  read,  ' '  Use  as  many  pieces 
as  possible"  rather  than  "as  few,"  as  formerly.  This,  however, 
would  be  an  extreme  teaching,  since  it  would  mean  the  expenditure 
of  too  much  time  over  an  operation.  It  is,  nevertheless,  a  sign-board 
pointing  in  the  right  direction. 

We  may  obtain  square  blocks,  and  rolls  cut  into  short  lengths.  To 
me,  both  of  these  are  the  lazy  man's  adoptions.  He  asks  the  manu- 
facturer to  do  for  him  that  which  he  should  do  for  himself  As  I  do' 
not  like  patent  medicines,  of  which  a  stated  dose  will  cure  an  unspeci- 
fied individual,  so  neither  do  I  fancy  gold  prepared  to  fit  unseen  cavities. 
How  does  it  work  ?  If  we  obtain  an  assortment,  as  we  probably 
would,  we  begin  instinctively  by  using  up  the  smaller  pieces.  As  we 
find  the  stock  decreasing  we  are  compelled  to  use  larger  and  larger 
pieces,  till  at  length  we  reach  a  condition  where  having  a  small  cavity 
before  us,  and  only  large  blocks  in  the  gold  drawer,  we  either  im- 
properly fill  with  too  large  pieces  or  else  we  stop  to  cut  up  the  blocks, 
causing  more  or  less  compression,  and  generally  poorly-shaped  pellets. 

I  prefer,  therefore,  to  procure  gold  foil  in  books,  and  roll  and  cut 
it  for  each  case  immediately  before  inserting  it  into  the  cavity.  I  have 
never  found  any  way  of  keeping  gold  in  the  office,  superior  to  leaving 
it  between  the  paper  leaves  of  the  books.  Foil  in  books  may  be  ob- 
tained "  trimmed"  or  "untrimmed. "  The  latter  sells  at  a  lower  rate, 
and  is  not  only  as  good,  but  really  is  the  same  thing  as  the  trimmed. 
This  is  a  legitimate  economy  therefore,  though  it  is  a  rare  thing  tO' 
find  a  strictly  economical  dentist  who  is  at  the  same  time  a  capable  one. 
Dentistry  is  not  a  good  field  for  economy.     The  patient  should  be 


GOLD  AS  A  FILLING-MA  TERIAL.  75 

given  the  best  of  everything,  and  the  best  is  usually  the  highest 
priced.  As  good  a  way  of  cutting  gold  as  any  is  to  tear  from  the  book 
two  or  three  leaves,  with  the  foil  between,  and  with  sharp  shears  cut 
both  gold  and  paper.  This  avoids  the  unpleasant  accident  which  fre- 
quently happens  when  gold  is  cut  unprotected,  where  we  find  that  it 
sticks  to  the  edges  of  the  scissors.  These  strips  should  then  be  loosely 
rolled  into  ropes,  and  cut  into  pellets  suitable  to  the  case  for  which 
they  are  prepared.  To  illustrate  how  far  I  carry  this  principle,  I  need 
only  say  that  I  have  cut  a  strip  as  narrow  as  one-tenth  of  the  width 
of  the  sheet,  and  have  then  made  the  pellets  no  longer  than  their  width. 
I  further  state  that  this  can  be  done  so  dehcately  that  the  pellets  are 
proportionately  as  pliable — that  is  to  say  as  loosely  rolled — as  where  I 
used,  a  third  of  a  sheet,  which  is  the  maximum  width  to  be  resorted  to. 
With  tiny  pellets  of  this  character  I  fill  tiny  cavities  ;  those  made  with 
the  finest  of  rose  burs,  and  which  retain  the  filling  because  the  bur  is 
dipped  first  in  one  direction  and  then  in  an  opposite.  A  fiUing  of  this 
kind  may  be  smaller  by  far  than  the  head  of  a  pin,  and  yet  have  re- 
quired a  dozen  or  more  pellets.  I  have  more  confidence  in  a  filling 
so  made,  than  I  would  have  in  one  made  with  a  single  large  pellet, 
however  dexterously  manipulated,  and  however  bright  it  may  be  made 
to  appear.  I  have  seen  a  clinician  fill  teeth  in  this  latter  way,  as  a 
demonstration  of  "  irapid  work,"  and  I  have  been  impressed  with  the 
idea  that  we  should  make  rapidity  subservient  to  perfection . 

There  is  an  extreme  danger  which  should  be  cautiously  avoided 
in  using  cohesive  gold  pellets.  I  think  it  is  usually  preferable  to 
fill  undercuts  with  crystal,  or  some  other  of  the  plastic  golds. 
Where  this  is  not  done,  the  foil  may  be  used,  but  care  must  be  ob- 
served in  the  direction  now  to  be  indicated.  An  undercut  usually 
produces  a  weakening  of  a  neighboring  wall.  If  a  pellet  be  taken 
which  is  much  too  large  for  the  undercut,  and  is  doubled  on  itself  as 
it  is  forced  into  place,  the  instrument  being  between  the  folds,  the 
whole  acts  as  a  wedge,  producing  a  strain  against  that  wall.  This  may 
fracture  it  so  that  it  breaks  away,  or  it  may  crack  it  so  slightly  that 
the  accident  may  not  be  noted.  Then,  when  decay  creeps  in,  the 
usual  sermon  may  be  preached  :  "  The  tooth  has  decayed  around  my 
filling,  but  the  filling  is  all  right."  It  is  well  to  be  sure  that  the 
plugger  chosen  can  be  driven  to  the  bottom  of  an  undercut  without 
danger,  and  then  the  pellet  should  be  small  enough  to  enter  the  space 
without  doubling,  though  large  enough  to  jam  slighdy  ;  when  so 
placed,  it  may  be  driven  home  with  the  plugger,  which  in  this  case  is 
not  between  the  gold,  but  behind  it.  The  action  is  to' compress  the 
gold  toward  the  bottom  of  the  cavity,  and  not  laterally  between  the 
walls  and  the  sides  of  the  instrument.  This  caution  to  use  small 
pieces  should  be  observed  until  the  undercut  is  entirely  filled.    Another 


76  METHODS  OF  FILLING  TEETH. 

thing  is  that  perfect  cohesion  is  gained  by  this,  and  is  not  obtained  if 
any  other  plan  be  adopted.  How  often  have  we  all  removed  some 
other  vian^  sjilling,  taking  it  away  in  a  solid  mass  but  leaving  gold  in 
the  bottom  of  the  undercut  ?  What  does  that  mean  ?  It  means  that 
the  undercuts  were  presumably  made,  to  assist  in  the  retention  of  the 
filling,  but  because  of  the  manner  of  packing  the  gold,  no  such  result 
accrued.  The  explanation  lies  in  this  :  Gold  loses  its  cohesive  prop- 
erty in  proportion  as  it  is  condensed.  Thus  having  partly  filled  an 
undercut,  the  gold  placed  therein  remaining  in  position  because  it  is 
wedged  in,  we  have  before  us  a  small  surface  of  gold  presented,  and 
an  undercut  lessened  in  depth.  If  the  next  pellet  does  not  cohere, 
we  would  have  been  as  well  off  with  a  shallower  undercut.  If  a  pellet 
which  is  too  large  be  now  used,  the  pressure  of  the  plugger  begins 
to  condense  it  before  it  is  made  to  touch  the  gold  in  the  bottom  of  the 
groove,  the  result  being  that  there  is  less  cohesion,  if  indeed  there  is 
any.  The  principle,  then,  is  to  begin  with  a  piece  just  large  enough 
to  be  wedged  in  without  lateral  pressure,  and  to  add  next  a  similar 
piece,  or  one  even  smaller,  so  that  it  will  readily  reach  the  first,  a?id 
cohere  with  it  be/ore  miy  great  pressure  has  been  exerted.  In  other 
words,  it  should  be  condensed  after  it  has  cohered,  instead  of  before. 
This  one  principle  observed,  will  make  approximal  fillings  permanent, 
which  would  fail  where  it  is  neglected. 

For  similar  reasons,  if  a  pellet  by  any  accident  has  become  slightly 
compressed,  it  should  be  placed  in  the  waste-box.  It  should  under 
no  circumstances  be  put  with  the  good  gold,  and  finally  used  in  some 
large  cavity.  That  is  an  economy  which  is  reprehensible,  the  more 
so  because  it  cannot  be  detected.  I  saw  this  done  once  in  a  contour 
filling,  by  a  friend  for  whom  I  was  malleting.  I  subsequently  saw  the 
same  filling,  otherwise  beautiful,  with  about  one-quarter  of  its  corner 
broken  off.  I  thought  at  the  time  that  I  understood  the  accident,  and 
I  think  so  still.  The  filling  had  a  flaw  in  it,  and  the  flaw  was  caused  by 
that  bit  of  partly  condensed,  and,  therefore,  imperfectly  cohesive,  gold. 

This  cornpression  of  a  pellet  before  it  is  brought  into  contact  with 
the  surface  of  the  already  packed  gold  brings  us  to  another  point  of 
great  importance.  In  the  approximal  surfaces  of  unusually  long 
bicuspids  we  may  be  compelled  to  work  with  insufficient  space.  I 
mean  space  insufficient  for  the  placing  of  a  pellet  of  usual  size  without 
compression.  The  cavity  may  be  one  in  which  we  would  be  author- 
ized to  use  fairly  large  pellets  ;  it  may  be  one  in  which  to  use  very 
small  pellets  would  mean  to  compel  the  patient  to  submit  to  too  long 
an  operation.  Yet  we  may  find  that  every  pellet,  as  it  is  pressed  to 
place  either  between  the  teeth  or  through  the  possible  orifice  in  the 
cutting-surface  of  the  tooth,  becomes  partly  compressed.  What  must 
be  done  ?    After  showing  that  such  pellets  do  not  produce  good  results, 


USES  OF  HEAVY  GOLD.  JJ 

it  remains  only  to  say  that  in  such  circumstances  they  should  not  be 
used  at  all.  The  entire  filling  must  be  made  with  rolled  gold,  other- 
wise known  as  heavy  foil.  This  brings  me  to  as  good  a  place  as  any 
for  explaining  what  I  think  the  relative  values  of  the  three  forms  of 
gold.  The  use  of  crystal  I  have  told.  I  would  depend  upon  pellets 
for  everything  between  the  crystal  and  the  last  third  of  the  filling, 
which  should  invariably  be  made  with  heavy  foil. 

My  reason  for  this  is  that  experience  has  taught  me  that  fillings 
completed,  or  made  throughout  with  heavy  foil,  will  retain  their 
smooth,  polished  surfaces  much  longer  than  any  made  otherwise.  I 
have  a  theory  to  offer  as  a  cause  for  this.  If  we  take  a  strip  of  foil 
and  roll  it  into  a  rope,  there  is  necessarily  air  between  the  folds.  If, 
now,  we  cut  this  into  pellets,  with  each  snip  of  the  scissors  we  com- 
press the  edges  of  a  pellet,  practically  sealing  within  it  several  cells  of 
air.  When  filling  with  these,  we  only  compress  the  gold  as  much  as 
the  contained  air  will  permit.  It  will  be  claimed  here  that  this  is  an 
argument,  first,  against  using  such  pellets  at  all,  and  secondly,  in  favor 
of  replacing  them  with  the  blocks  or  cylinders  which  I  have  con- 
demned. My  reply  to  the  first  would  be  that  pellets  of  this  kind,  in 
spite  of  the  argument,  will  make  a  good  gold  filling,  even  used  at  the 
surface,  and  where  heavy  gold  is  employed  for  the  last  third  of  the 
filling,  they  certainly  serve  all  our  purpose.  To  the  second,  while 
admitting  that  the  block  or  cylinder  has  the  edges  open,  thus  appear- 
ing to  offer  an  outlet  for  any  contained  air,  they  are  nevertheless  open 
to  exactly  the  same  objection,  because  to  surely  expel  the  air  it  would 
be  necessary  in  condensing  to  begin  at  one  point  and  then  work 
exactly  uniformly  toward  the  edges  of  the  pellet,  or  to  start  at  one  end 
and  approach  the  other,  neither  of  which  is  probably  done  in  any 
instance,  and  surely  not  with  every  block  or  cylinder.  The  heavy  foil 
is  better  because  it  is  of  a  single  thickness,  and  does  not  contain  any 
air  at  the  start.  Yet,  even  with  this  magnificent  material,  care  must 
be  observed  in  the  same  direction,  for  if  not  properly  attached  and 
condensed,  air-cells  will  be  produced. 

I  now  come  to  a  discussion  of  the  merits  and  usefulness  of  heavy 
or  rolled  gold.  It  is  procurable  in  various  thicknesses,  numbered  30, 
40,  60,  and  120.  The  last  is  an  extremity  to  which  we  need  rarely 
if  ever  resort.  Numbers  30  and  60  are  sufficient  for  all  purposes,  and 
we  may  practically  produce  the  latter  by  folding  the  former  once,  be- 
fore cutting. 

The  earlier  advocates  of  this  form  of  gold  were  so  enthusiastic  over 
it  that  they  claimed  to  depend  upon  it  entirely.  The  theory  was  that 
the  more  gold  one  could  crowd  into  a  cavity,  the  better  the  result. 
This  is  not  true.  The  supreme  demand  upon  any  filling  is  that  it 
shall  present  a  durable  surface,  and  be  in  close  contact  with  all  its 


78  METHODS  OF  FILLING   TEETH. 

walls.  It  could  be  hollow  in  the  center,  and  serve  as  well.  Indeed, 
hollow  fillings  have  been  made,  merely  to  show  dexterity,  and  they 
have  preserved  the  teeth.  In  large  cavities  surrounded  with  strong 
walls  it  is  not  very  difficult  to  accomplish  this.  The  floor  and  sides 
are  covered  with  a  solid  but  thin  veneer,  and  then  the  top  is  roofed 
over  by  building  from  the  margins  toward  the  center,  finally  closing 
the  last  orifice,  and  leaving  the  interior  of  the  filling  hollow.  It  is  not 
quantity  of  gold  therefore  that  is  needed.  At  the  same  time  we  must 
have  solidity  at  the  surface,  as  that  means  durability.  This  is  best 
achieved  when  we  depend  upon  heavy  gold  for  at  least  the  final  third. 
A  filling  so  completed  will  receive  a  higher  and  more  beautiful  finish, 
and  will  retain  its  luster  longer  than  any  other. 

I  have  hinted  that  there  are  places,  however,  where  we  must  de- 
pend upon  this  gold  entirely.  I  will  describe  them  in  more  detail. 
We  have  all  of  us  seen,  in  crowded  jaws,  bicuspids  so  solidly  rooted 
that  it  becomes  almost  impossible  to  obtain  extensive  separation. 
Approximal  cavities  in  these  teeth,  especially  where  they  reach  almost 
to  the  gum,  are  most  trying.  The  orifice  at  the  masticating  surface 
is  so  small  that  an  ordinary  pellet  is  compressed  in  passing,  and  yet, 
when  within  the  cavity,  is  so  loose  that  it  is  most  difficult  to  attach  it 
firmly  against  any  gold  already  in  position.  Our  manipulations  only 
compress  it  more,  when  in  the  end  most  probably  it  becomes  a  non- 
plastic  nodule  unfitted  for  use.  It  is  here  that  we  may  turn  to  heavy 
gold  with  entire  confidence.  Because  of  its  thinness  it  can  readily  be 
passed  between  the  teeth  and  led  into  place,  when  its  impaction  be- 
comes comparatively  easy.  Undoubtedly  a  tooth  thus  filled  entirely 
with  this  material  will  be  well  filled.  If  the  question  be  asked,  Why 
not  do  this  in  all  cases  ?  the  reply  is,  that  to  do  so  would  be  a  waste 
of  time,  as  it  takes  longer  to  fill  exclusively  with  heavy  foil  than  where 
we  use  a  plastic,  pellets,  or  both,  for  the  first  two-thirds. 

Another  most  important  position  for  heavy  foil  is  where  in,  let  us 
say  a  lower  molar,  we  find  a  cavity  in  the  masticating  surface,  and 
another  in  the  posterior  approximal.  Imagine  this  latter  to  be  what 
we  term  a  saucer-shaped  cavity, — one  of  those  exasperating  places 
where  we  find  absolutely  no  retentive  shape,  and  a  tooth  so  highly 
organized  that  every  attempt  to  use  the  engine,  or  an  excavator,  causes 
excruciating  agony  to  the  patient.  It  is  seen  that  if  the  two  cavities 
be  united,  the  whole  would  at  once  receive  and  retain  a  filling  perma- 
nently. This  is  done,  but  now  the  question  arises.  At  what  point  shall 
the  fining  be  started  ?  It  is  simply  impossible  to  begin  at  the  bottom 
of  the  approximal  cavity,  because  there  is  no  retentive  pit  or  groove 
to  aid  us.  We  therefore  begin  at  the  wrong  end,  according  to  ordi- 
nary principles  ;  that  is,  we  begin  at  the  top  and  work  downward. 
We  fill  the  cavity  in  the  masticating  surface,  and  then  try  to  build  over 


CrSES  OF  HEA  VY  GOLD.  79 

and  down  into  the  approximal  portion.  This  is  very  difficult  with  any- 
material,  and  trebly  so  with  anything  except  heavy  foil.  The  pro- 
cedure is  to  only  partly  fill  the  upper  cavity,  and  then,  using  No.  60 
rolled  gold,  work  over  the  edge,  down  into  the  approximal  extension. 
The  stiffness  of  the  gold,  and  the  fact  that  it  is  a  single  thickness,  tend 
to  make  this  comparatively  simple.  Here  is  a  place  where  the  foot- 
plugger  is  pre-eminently  useful.  With  it  a  piece  of  gold  may  be  first 
well  attached  to  that  already  in  place,  and  then  the  end  led  over  the 
edge  and  against  the  wall  of  the  approximal  cavity.  A  second  piece 
treated  similarly  will  make  sufficient  stiffness  to  insure  the  overlap- 
ping part  against  riding  up.  Then  a  step  further  may  be  taken,  and  so 
on,  until  all  the  walls  and  floor  of  the  approximal  cavity  are  covered, 
when  the  completion  of  the  work  becomes  simple  with  any  kind  of 
gold  preferred.  Care  should  be  taken  that  as  each  new  piece  is 
added,  it  be  first  securely  attached  in  the  upper  cavity.  This  is  why 
I  would  not  fill  that  part  too  full  at  the  outset. 

There  is  a  most  important  use  for  heavy  foil,  in  cases  which  are 
frequently  very  annoying.  I  allude  to  cavities  at  the  labial  festoon 
in  anterior  teeth.  We  not  infrequently  find  cavities  which  defy  the 
application  of  the  best  clamp  at  hand.  Do  what  we  will,  there  is  a 
tendency  on  the  part  of  the  clamp  to  slip  so  that  it  passes  over  the 
edge  and  impinges  within  the  cavity  proper.  In.  these  cases  proceed 
as  follows  :  Get  the  clamp  into  place,  and  hold  it  there  with  one  hand 
while  the  packing  of  the  gold  is  begun.  As  rapidly  as  can  be  done 
with  safety,  fill  along  the  upper  edge  until  there  is  a  good  starting- 
point  made,  with  either  crystal  gold  or  pellets.  Then  take  No.  60 
foil,  cut  into  pieces  about  as  long  as  the  extent  of  the  cavity  and  not 
too  wide.  Take  one  of  these  pieces  and  lay  it  upon  the  gold  already 
fixed,  so  that  about  half  of  it  protrudes  above  the  gingival  wall  and 
rests  against  the  clamp.  Mallet  this  down  only  as  far  as  it  touches  the 
filling,  but  leave  the  protruding  portion.  Be  very  careful,  however, 
that  the  margin  isfs-^properly  covered.  Repeat  this  three  or  four  times. 
This  will  give  us,  say  four  thicknesses  resting  against  the  clamp.  If  this 
be  now  malleted  down,  a  ridge  will  be  formed,  extending  above  the 
edge  of  the  cavity,  perfectly  protecting  the  operator  from  any  slipping 
of  the  clamp.  The  continuance  of  the  filling  will  become  a  simple 
and  pleasant  task. 

In  very  small  cavities  in  the  same  neighborhood  I  have  successfully 
filled  with  gold,  without  using  the  dam  at  all,  by  thus  throwing  up  a 
barrier  of  gold,  and  then  working  rapidly.  I  have  in  some  instances 
made  this  gold  wall  so  high  that  at  the  end  I  have  turned  it  down  upon 
the  filling  and  malleted  it  soHd,  though  the  upper  side  was  wet  from 
accumulated  mucus. 

The  same  general  plan,  though  to  a  more  limited  extent,  may  be 


8o  METHODS  OF  FILLING  TEETH. 

advantageously  resorted  to  in  those  cases  where,  a  hgature  being  an 
essential,  it  is  found  just  possible  to  press  it  above  the  cavity  margin. 
There  is  constant  danger  of  its  slipping.  Use  the  heavy  foil  and  form 
a  ridge  beyond  the  margin,  as  has  been  described,  and  there  will  be 
no  further  reason  for  anxiety  as  to  the  ligature. 

Sometimes  in  a  large  cavity  there  is  an  underlying  layer  of  oxy- 
phosphate,  either  placed  by  the  operator,  or  found  in  the  cavity  from, 
which  a  leaking  filling  has  been  removed.  For  good  reasons  in  the 
individual  case,  it  may  be  desirable  to  fill  with  gold  without  disturbing 
this.  Under  the  action  of  the  mallet,  occasionally  a  dust  is  formed 
by  particles  being  broken  from  this  layer  of  phosphate.  This  is  not 
only  annoying,  but  it  interferes  materially  by  preventing  cohesion  of 
the  gold.  The  filling  having  been  fairly  well  started,  a  single  thick- 
ness of  heavy  foil  may  be  attached,  and  then  laid  down,  completely 
covering  the  phosphate,  and  the  trouble  is  remedied. 

There  is  one  more  use  of  heavy  foil  to  which  I  will  specially  allude, 
and  that  will  lead  me  to  the  proper  method  of  manipulating  it. 

Once  more  let  us  imagine  a  cavity  in  the  approximal  surface  of  a 
bicuspid.  While  we  have  apparently  sufficient  space,  or  so  judge  at 
the  outset,  as  the  work  progresses  we  wish  that  we  had  obtained, 
more  ;  or  let  us  say  that  more  was  unobtainable.  The  result  not  in- 
frequently is  that  near  the  end  we  find  that  the  cavity  is  perhaps  filled 
so  far  as  having  its  surfaces  covered,  but  we  wish  to  add  more  gold 
for  the  sake  of  contour  ;  the  filUng  is  flat,  whereas  we  wish  it  rounding. 
The  space  will  just  admit  a  thin  burnisher.  In  such  a  condition  we 
find  that  there  are  parts  of  the  filling,  about  its  center,  which  cannot 
well  be  reached  with  a  plugger.  I  proceed  as  follows,  and  I  will  say 
here  that  this  is  not  to  be  confounded  with  the  Herbst  method.  I  lav 
a  piece  of  heavy  foil,  preferably  No.  30,  within  the  space  and  against 
the  surface  of  the  filling.  Then  with  a  thin,  flat,  clean,  and  warm 
burnisher  I  burnish  the  added  piece  vigorously,  whereupon  it  unites 
thoroughly  with  the  filling.  In  a  similar  way  I  pro€?eed,  adding  gold 
as  long  as  needed,  and  completing  my  contour.  This  makes  a  hard, 
surface,  and  though  I  have  practiced  this  for  over  ten  years,  I  have 
never  had  such  portion  of  my  filling  scale  off.  Another,  and  perhaps 
more  frequent,  occasion  for  this  method  is  where  from  long  malleting, 
or  other  cause,  a  tooth  is  so  sore  that  it  is  cruel  to  use  the  mallet  any 
longer.  I  find  that  ordinary  hand-pressure  in  this  case  results  in  no 
gain.  Then  I  resort  to  the  heavy  foil  and  burnisher,  with  satisfac- 
tion to  myself  and  patient.  I  would  impress  one  fact  upon  the  mind 
of  the  reader  :  Never  attempt  this  method  until  all  margins  are  covered, 
and  never  try  it  with  anything  but  heavy  gold. 

I  believe  that  the  common  practice  is  to  cut  heavy  foil  into  narrow 
strips  of  considerable  length,  and  fold  it  over  and  over  as  it  is  packed.. 


MANIPULA  riON  OF  HE  A  J'} '  FOIL.  8  I 

There  is  no  objection  to  this  where  the  operator  has  acquired  the  neces- 
sary skill.  The  beginner,  however,  will  find  it  unsatisfactory,  because 
it  is  difficult.  In  fact,  heavy  foil  is  the  most  troublesome  of  all  golds 
with  which  to  fill  teeth.  It  must  be  remembered  that  it  is  the  least 
pliable,  and  therefore  we  readily  see  that  it  will  be  found  most  un- 
yielding in  the  hands  of  one  who  resorts  to  it  for  the  first  time.  It 
must  follow,  then,  that  the  less  of  it  the  operator  has  to  contend  with 
the  more  likely  will  he  be  to  succeed.  There  is  also  a  strong  objec- 
tion to  using  the  gold  in  long  strips.  It  will  frequently  be  found 
that  it  does  not  turn  over  so  as  to  assume  the  direction  desired.  Then 
when  it  is  forced  into  proper  position  an  angle  is  crimped  up,  which 
when  malleted  down  forms  a  hill,  and  is  very  resistant  besides.  I 
therefore  think  it  best  to  abandon  the  strip,  as  I  would  the  rope, 
and  rely  upon  pieces  not  much,  if  any,  longer  than  the  cavity.  Of 
course  there  is  not  much  objection  to  making  one  fold  with  it.  Here, 
then,  as  with  all  the  other  forms  of  gold,  I  advocate  small  pieces. 
It  may  seem  that  this  makes  a  man  a  slow  operator,  but  in  the  first 
place  it  is  better  to  be  thorough  than  rapid  ;  secondly,  thoroughness 
does  not  necessarily  mean  slothfulness  ;  and  thirdly,  it  is  a  fact  that 
these  methods  may  be  followed  and  yet  result  in  rapid  work.  Even 
if  it  did  not,  the  pleasure  of  seeing  fillings  five  and  ten  years  old,  with 
beautiful  smooth  surfaces,  will  repay  for  the  outlay  of  time,  patience, 
and  conscientiousness. 

As  with  other  golds,  I  prefer  small  points  in  packing  the  heavy  foils, 
and  certainly  the  foot-plugger  is  at  its  worst  when  we  are  using  rolled 
gold.  Except  when  using  a  burnisher  as  described,  it  is  a  difficult  and 
slow  process  to  pack  it  by  hand.  Better  and  more  rapid  work  results 
with  a  mallet,  and  better  still  where  the  mallet  is  one  with  rapid 
stroke,  as  the  electric  or  the  engine  mallet. 

Before  leaving  this  I  will  point  out  one  disadvantage  of  heavy  foil. 
Being  of  a  single  layer,  it  is  difficult  with  it  to  alter  the  form  of  the 
surface  against  which  it  is  packed.  For  example,  suppose  that  in 
following  and  covering  the  walls  of  a  cavity  the  center  is  left  some- 
what hollow.  If  now  we  begin  to  add  heavy  foil,  the  hollow  will 
not  be  materially  filled  up.  The  best  plan  is  to  alternate  with  pellets, 
placing  a  pellet  in  the  hollow,  packing  it,  then  using  the  heavy  foil, 
then  another  pellet,  and  so  on  till  the  hollow  is  filled  flush,  when  we 
may  continue  with  the  heavy  foil  alone,  till  the  whole  's  completed. 
Another  thing  to  be  carefully  guarded  against  is  to  allow  a  piece  of 
heavy  foil  to  become  rumpled  or  crinkled  when  placing  it  between 
teeth.  It  will  be  found  doubly  resistant  in  such  cases,  and  so  stiff 
that  a  good  result  is  hardly  attainable.     Use  it  smooth. 

Gold  in  Combination  with  OxypJwsphate. — I  come  now  to  the  de- 
scription of  a  method  of  filling  teeth  which  in  proportion  to  its  value 


82  METHODS  OF  FILLING   TEETH. 

has  been  too  little  considered.  It  is  a  general  practice  in  many  cases 
to  interpose  a  stratum  of  oxyphosphate  between  tooth  and  gold.  The 
ordinary  custom  is  to  allow  the  plastic  to  set,  before  proceeding  with 
the  insertion  of  gold.  I  touched  slightly  upon  this  subject  when  dis- 
cussing oxyphosphate,  but  I  have  reserved  until  this  time  a  fuller  de- 
scription of  the  method  and  the  conditions  in  which  it  is  indicated. 
There  are  many  cases  where  dentine  is  excruciatingly  sensitive  while 
the  tooth  is  being  prepared  for  filling.  I  allude  to  teeth  in  which  there 
is  not  a  suspicion  of  pulp-exposure.  I  state  dogmatically  and  em- 
phatically, that  these  hypersensitive  teeth  should  7iever  be  filled  with  gold, 
allowing  the  metal  to  come  in  contact  with  the  dentine.  To  emphasize 
the  point  which  I  wish  to  make,  let  us  briefly  consider  the  cause  of. 
sensitiveness  in  dentine.  Dentine  is  made  up  of  succeeding  stratifica- 
tions of  hollow  tubes, — the  dentinal  tubuli.  These  tubes  contain  living 
matter ;  whether  fluid,  semi-fluid,  or  true  nerve-tissue,  is  undetermined 
and  for  my  purpose  immaterial.  The  contents  of  these  tubes  lead 
directly  to,  and  come  into  actual  contact  with  the  pulp  itself  This 
pulp  is  highly  organized,  and  traversed  v/ith  nerve-filaments  to  such 
an  extent  that  no  part  of  it  may  be  touched  without  responding  by  a 
painful  form  of  sensation.  Consequently,  the  contents  of  the  tubuli 
rest  against  a  tissue  which  reports  painfully  upon  the  slightest  provo- 
cation. These  in  their  turn,  whatever  their  formation,  have  the  power 
of  transmitting  impressions.  Thus,  when  an  excavator  cuts  across 
them,  pressure  is  produced,  and  transmitted  to  the  pulp,  which  re- 
sponds at  once.  Now,  the  dentine  is  sensitive,  or  responsive  in  this 
way,  in  exact  proportion  to  the  relative  size  of  the  tubuli  and  their 
contents.  That  which  has  a  large  number  of  tubuli,  with  small  diame- 
ters, will  be  less  sensitive  than  that  which  has  fewer  tubuli  of  larger 
size,  for  here  we  find  more  living  tissue,  more  power  to  transmit 
pressure,  and  consequently  more  pain.  The  patient  says,  "Doctor, 
the  nerve  is  exposed,  because  you  hurt  me  very  much. ' '  The  learned 
gentleman  remarks,  ' '  No,  madam  ;  there  is  no  exposure.  The  den- 
tine is  sensitive,  that  is  all."  That  is  all !  But  microscopically  speak- 
ing the  patient  is  correct.  The  pulp  is  exposed  in  hundreds  of  places. 
Every  gapi7ig  tubule  is  an  open  passage  to  the  pulp.  Hypersensitive 
teeth,  those  which  I  say  should  not  receive  gold  directly  against  the 
dentine,  are  those  where  the  tubuli  are  abnormally  large.  To  place 
against  the  open  ends  of  these  tubes  a  mass  of  'inetal  of  such  conduc- 
tivity as  gold,  is  to  invite,  and  ofteyi  to  induce,  the  death  of  the  pulp. 
These  are  the  teeth  where  the  patient  returns  and  says,  ' '  Doctor,  that 
tooth  hurts  whenever  I  drink  cold  or  hot  drinks."  The  dentist  re- 
plies, ' '  That  will  pass  off. ' '  This  is  true,  and  it  occurs  in  one  of  two 
ways.  Sometimes  the  pulp  dies,  after  which  of  course  hot  drinks  do 
not  cause  sensation.     Then,  again.  Nature  may  succeed  in  repairing 


GOLD  AND  OXYPHOSPHATE.  83 

the  damage  done  by  the  operator.  She,  with  her  wonderful  intelH- 
gence,  at  once  begins  a  deposition  of  Hme-salts  against  the  surface  of 
the  gold.  The  tubuli  thicken  as  to  their  walls,  so  that  their  contents 
and  consequently  their  power  to  transmit  impressions  diminish.  So 
much  for  the  physiology  of  the  condition.  Let  us  now  consider  the 
treatment.  It  is  to  smear  the  dentine  with  oxyphosphate^  and  while 
this  is  still  plastic,  and  of  sticky  consiste7icy ,  crowd  in  two  or  three  well- 
annealed  pellets  of  gold.  In  large  cavities  crystal  is  better.  The 
phosphate  must  now  be  left  to  set  thoroughly.  Then  the  gold  may 
be  compressed,  and  will  be  practically  cemented  into  place.  This  aids 
in  its  retention,  but  should  not  be  depended  upon  to  the  exclusion  of  the 
usual  vtethods  of  shaping  the  cavity.  The  next  step  is  to  carefully 
scrape  off  all  oxyphosphate  which  reaches  or  covers  the  margins. 
The  fining  may  then  be  completed  with  any  gold.  It  will  be  claimed 
that  even  oxyphosphate  is  a  good  conductor  of  heat.  This  is  true, 
but  it  is  less  so  than  gold.  Besides,  the  conductivity  of  a  material 
depends  upon  its  homogeneity.  The  fact  that  a  filling  of  this  char- 
acter is  composed  of  two  masses,  gold  and  oxyphosphate,  renders  the 
whole  a  poorer  conductor  than  if  it  were  made  of  either  exclusively. 

Beginning,  then,  from  the  point  of  using  this  method  in  sensitive 
teeth,  we  quickly  determine  to  employ  it  in  cases  where  the  pulp  is 
really  nearly  approached.  Here  a  greater  mass  of  oxyphosphate  may 
be  used.  When  we  have  become  dexterous  in  the  operation  in  these 
two  classes  of  teeth,  we  soon  begin  to  wonder  why  it  is  not  applicable 
in  those  large  or  deep  cavities  of  retentive  shape,  but  where  we  find  it 
difficult  to  obtain  a  starting-point.  At  once  we  see  the  advantage  of 
using  the  phosphate/^;'  ce?nenting  in  the  first  pieces ,  merely  to  start  a 
filli7ig.  As  it  is  perfectly  feasible,  is  it  not  more  sensible  than  to  drill 
a  pit,  or  bur  out  an  extra  groove?  So  that  having  passed  through 
all  the  phases,  beginning  with  ridiculing  the  method,  I  have  almost 
reached  the  point  where  I  use  it  exclusively.  Where  I  do  not  employ 
it  is  mainly  in  cavities  which  are  quite  small,  or  where  the  immediate 
circumstances  seem  to  make  it  less  convenient  or  advisable  than  to 
depend  upon  gold  alone.  It  is  a  habit  that  will  grow  upon  a  dentist, 
and  the  result  upon  the  patients  in  his  practice  will  be  a  lessening  of 
the  number  of  those  reports  about  teeth  being  sensitive  after  fiUing. 
Of  course  there  are  some  teeth  which  will  be  responsive  to  hot  and 
cold,  even  after  this  has  been  done.  Then  the  dentist  may  be  com- 
forted with  the  thought  that  it  would  have  been  worse  if  gold  alone 
had  been  used.     Indeed,  the  pulp  would  most  probably  have  died. 

Gold  ajid  Platinum. — This  is  a  preparation  furnished  by  some 
manufacturers.  The  exact  proportions  of  the  two  metals  I  do  not 
know,  but  there  is  enough  of  the  platinum  to  materially  afiect  the 
color  of  the  -finished  filling,  though  during  the  operation  there  will  be 


84  METHODS  OF  FILLING   TEETH. 

little,  if  any,  dift'erence  in  appearance.  In  the  rough,  the  general 
surface  will  resemble  any  ordinary  gold,  but  as  soon  as  a  bur  or  stone 
is  passed  over  it  the  platinum  asserts  itself,  and  the  yellow  almost 
vanishes,  giving  place  to  a  color  which  is  not  as  beautiful  as  either 
gold  or  platinum  alone.  This  matter  of  color  I  dwell  upon,  because 
to  me  it  has  been  so  objectionable  that  I  have  almost  abandoned  the 
material.  I  once  had  to  build  down  the  lower  third  of  a  living  lateral 
incisor,  broken  off  by  a  fall.  For  some  reason,  which  I  have  never 
explained  satisfactorily  to  myself,  I  used  this  combination.  The  patient 
was  charmed,  because  her  one  dread  was  that  she  would  show  a  lot  of 
gold.  I  suppose  it  was  mainly  to  humor  this  fancy  that  I  did  not 
depend  upon  gold  alone.  As  soon  as  she  stepped  out  of  the  chair  and 
stood  a  few  feet  from  me,  I  realized  what  a  mistake  I  had  made.  The 
fining  did  not  show  as  much  as  gold,  because,  except  in  bright  light, 
it  did  not  show  at  all.  It  looked  so  dark  that  practically  the  tooth 
seemed  unfilled.  To  my  mind,  therefore,  it  is  contraindicated  for 
ordinary  work  in  the  front  of  the  mouth. 

An  advantage  which  it  possesses  over  gold  alone  is  that  it  pro- 
duces a  much  more  resistant  surface.  That  is,  it  is  tougher,  or,  to 
express  it  otherwise,  more  dense.  This  quality  would  indicate  its  use 
where  we  find  a  whole  set  of  otherwise  sound  teeth  being  worn  away 
by  abrasion  during  mastication.  Some  men  chew  so  hard  that  they 
actually  wear  out  their  teeth.  Ordinary  gold  fillings  only  very  slightly 
check  the  havoc  which  is  being  done.  If,  however,  we  soHdly  fill  all 
the  molars  with  gold  and  platinum,  further  mischief  will  be  prevented. 
For  similar  reasons  it  should  be  employed  where,  in  cases  of  pyorrhea, 
it  becomes  expedient  to  unite  two  teeth  by  a  filling  extending  across 
from  one  into  the  other,  covering  a  platinum  bar.  The  hardest  possible 
filling  is  desirable  in  these  cases,  and  is  obtainable  with  this  material. 

Its  manipulation  deserves  a  few  words  of  description  by  way  of 
caution.  In  the  first  place,  care  must  be  taken  not  to  tear  the  surface, 
as  this  exposes  the  platinum,  and  thus  renders  it  non-cohesive  at  that 
point.  For  the  same  reason,  annealing  should  be  done  in  a  way  that 
will  not  risk  burning  off  the  gold.  There  are  annealing  apparatuses 
which  serve  very  well,  or  a  piece  of  mica  may  be  used  as  a  tray  to 
carry  the  foil  over  the  fiame  before  it  is  cut  up.  When  I  am  using 
this  material,  and  I  find  that  it  is  losing  its  cohesiveness,  I  lay  on  one 
or  two  pieces  of  heavy  gold  foil,  thus  producing  the  cohesive  quality 
in  the  surface  of  the  filling  once  more,  and  then  continue  with  the 
platinum  and  gold. 

Gold  and  Tin.— In  spite  of  the  high  authority  for  this  method,  it  is 
one  in  which  I  have  no  faith.  In  the  first  place,  I  think  we  make  a  great 
mistake  in  searching  out  as  many  materials  as  possible  with  which  to 
fill  teeth.     We  have  now  good  and  reliable  filling-materials,  which 


HOIJ'  TO  CONDENSE  GOLD.  85 

have  served  us  well  and  will  continue  to  do  so,  if  we  patiently  and 
conscientiously  apply  ourselves  to  the  acquirement  of  skill.  I  do 
occasionally  use  gold  and  platinum,  and  I  have  indicated  where,  when, 
and  why  I  do  so.  Tin  and  gold  does  not  appeal  to  me,  because  in  the 
first  place  the  want  which  it  is  supposed  to  fill  does  not  in  my  opinion 
exist.  It  is  said  to  last  well  where  gold  fails  at  the  gingival  margin. 
I  have  touched  upon  this  subject  before,  and  here  will  only  state  that 
I  think  failure  at  the  gingival  border  is  due  to  faulty  manipulation, 
rather  than  to  material.  Certainly  I  should  doubt  that  tin  and  gold 
would  succeed  where  gold  had  failed.  I  made  the  statement  once, 
before  an  advocate  of  this  method,  that  I  had  never  inserted  a  tin  and 
gold  filling,  but  that  I  had  taken  out  quite  a  number  of  them,  and 
they  were  not  of  that  consistency  described  in  written  reports, — that, 
in  fact,  they  had  proven  utter  failures.  The  gentleman  to  whom  I  am 
alluding  is  a  prominent  and  skillful  operator,  widely  known,  and  has 
given  many  clinics  upon  this  method.  At  this  time  he  was  filling  a 
tooth  while  I  looked  on.  In  reply  to  my  remark,  he  said  that  if  I 
had  taken  out  tin  and  gold  fillings  they  must  have  come  from  the 
hands  of  poor  operators,  or  at  least  men  unskilled  in  this  particular 
method.  Of  course  to  this  I  could  say  nothing.  The  patient  for 
whom  he  was  working  was  the  office  assistant  of  a  dentist,  a  friend  of 
mine,  and  I  had  thuS  a  chance  to  learn  the  result  in  this  very  case. 
Within  one  year  the  tin  and  gold  filling  was  leaking  so  badly  that  the 
tooth  ached,  so  that  it  was  removed  and  replaced  with  gold,  which 
is  still  doing  good  service.  I  believe  that  a  practitioner  may  be 
thoroughly  successful,  and  satisfactorily  serve  all  of  his  patients,  with- 
out any  knowledge  whatever  of  tin  and  gold  in  combination. 

Gold  and  Iridium. — This  is  a  combination  not  manufactured,  but 
procurable  upon  order.  It  is  a  piece  of  iridium  placed  between  two 
layers  of  gold,  and  then  the  three  rolled  into  one,  producing  what 
looks  like  heavy  gold.  It  is  very  hard,  and  so  difficult  to  manipulate 
that  it  barely  deserves  mention.  The  gold  and  platinum  will  serve 
every  purpose  for  which  this  last  combination  was  designed. 

How  to  Condefise  Gold. — What  we  term  "hand-pressure"  is  the 
first  principle  of  packing  and  condensing  gold  into  a  cavity.  It  has 
several  advantages  over  malleting,  and  some  distinct  disadvantages. 
Consequently  it  is  rarely  proper  to  depend  upon  it  alone,  and  I  might 
almost  say  the  same  of  the  exclusive  use  of  the  mallet.  A  dentist 
should  be  competent  to  employ  all  methods,  and  discriminating  enough 
to  know  how  to  alternate  them  to  advantage.  The  greatest  good 
gained  by  hand-pressure  is  that  the  gold  remains  more  cohesive  under 
this  method  than  in  connection  with  any  other.  I  am  not  prepared 
to  discuss  the  physics  of  this  phenomenon,  but  it  is  a  fact  long  ago  ob- 
served by  me  clinically,  and  I  have  sufficiently  tested  it  to  feel  safe  in 


86  METHODS  OF  FILLING   TEETH. 

making  the  following  dogmatic  statement  :  The  more  gradual  the 
pressure  exerted  upon  gold  foil  in  condensing  it,  the  less  it  loses  its 
quality  of  cohesiveness ;  and  vice  versa,  the  mo7'e  suddeyi,  sharp,  or 
rapid  the  blow  of  the  ham^ner,  the  less  cohesiveness  will  be  exhibited. 
This  is  a  very  important  statement,  and  being  true,  once  recognized 
should  prove  invaluable  to  the  operator.  For  example,  suppose  the 
Bonwill  mechanical  mallet,  with  a  very  rapid  stroke,  is  being  used  in. 
filling  a  cavity  ;  suppose  that  suddenly,  seemingly  without  reason,  the 
gold,  piece  after  piece,  refuses  to  cohere  with  that  already  packed. 
We  stop  and  examine  for  moisture,  but  find  none.  Then  we  try  an- 
other and  another  piece  ;  perhaps  they  fail,  or  they  may  cohere  only 
to  come  away  again  after  a  few  pieces  have  been  added.  What  is  to 
be  done  ?  Is  it  an  uncommon  experience  ?  I  think  it  will  be  recog- 
nized by  many.  If  the  reader,  the  next  time  he  is  in  that  predica- 
ment, will  pack  two  or  three  pellets  carefully  by  hand-pressure,  he  will 
possibly  be  astonished  at  the  fact  that  they  cohere  perfectly,  and  that 
as  soon  as  the  whole  surface  has  been  covered  with  the  new  gold  the 
mallet  may  be  resumed  satisfactorily.  This  is  intelligent  alternation 
of  forces.  Again,  suppose  a  large  cavity,  with  a  comparatively  small 
opening.  It  is  found  that  before  the  floor  is  covered,  the  mallet  seems 
to  have  a  tendency  to  induce  the  filling  to  leave  its  retaining-points  or 
grooves.  The  filling  becomes  loosened.  Again  and  again  this  loose 
piece  is  removed  and  the  work  restarted,  but  always  with  the  same 
result.  Begin  once  more,  and  fill  a  good  portion  of  the  cavity  by 
hand-pressure.  After  that,  continue  with  the  mallet,  and  all  will  be 
well.  Suppose  that  we  wish  to  use  large  pellets  in  a  large  cavity. 
Every  now  and  again  the  pellet  balls  up  under  the  mallet,  or  only  one 
end  of  it  coheres,  so  that  we  tear  off  and  discard  the  other  half  Here 
is  a  time  when  each  large  pellet  should  be  partly  condensed  by  hand  be- 
fore the  viallet  is  brought  into  use. 

The  disadvantages  of  hand- pressure  are  obvious.  It  is  slow,  it  is 
tedious  to  both  patient  and  operator,  and  it  does  not  produce  as  dense 
a  filling.  More  important  still,  it  is  a  fact  that  more  teeth  have  been 
actually  broken  by  hand-pressure  than  where  judicious  use  of  a  mallet 
has  been  depended  upon.  To  use  a  corkscrew  plugger  by  hand  in  a 
deep  undercut  of  an  incisor,  is  to  invite  the  fracture  of  the  corner. 
The  slightest  twist  of  the  instrument  brings  so  mighty  a  force  against 
frail  structure  that  the  disaster  is  inevitable.  This  is  a  lesson  that 
students  should  learn  theoretically,  rather  than  practically,  as  I  did. 
It  is  very  unpleasant  to  try  to  palliate  the  offense  to  the  patient. 
Again,  a  plugger  is  more  likely  to  slip  by  this  method  than  where  the 
mallet  is  in  use.  The  force  exerted  is  a  continuous  one,  and  practically 
limited  only  by  the  resistance.  Thus,  if  the  resistance  gives  way,  as 
when  the  instrument  rests  at  an  improper  angle  so  that  it  may  slide 


MALLETING.  8/ 

off  the  tooth,  the  pressure  carries  the  instrument  onward,  and  does 
damage.  It  may  be  only  to  tear  the  dam,  or  it  may  be  to  emerge 
through  the  cheek  of  the  patient  as  I  saw  happen  once,  or  it  may  be 
to  pass  completely  through  the  guard-finger  as  occurred  to  myself. 
These  little  accidents,  especially  like  the  last,  make  an  enduring  im- 
pression. 

The  advantages  of  malleting  gold  are  unanimously  admitted,  I  be- 
lieve. The  only  question  remaining  is,  ' '  What  mallet  shall  we 
choose?"  On  this  subject  I  have  little  to  say.  It  is  useless  to  dis- 
cuss the  merits  of  various  mallets,  for  as  many  opinions  can  be  ob- 
tained as  there  are  mallets,  or  men  using  them.  There  are  a  few 
points  in  connection  with  the  ones  most  used  to  which  it  may  be  prof- 
itable to  allude.  I  was  taught  to  use  the  automatic  mallet.  I  was  a 
strong  adherent  of  it  for  a  number  of  years.  I  feel  satisfied  that  good 
work  can  be  done  with  it, — as  good  as  with  any  other.  But  I  once 
had  a  tooth  in  my  own  head  filled  with  it,  and  have  never  used  it  on 
a  patient  since.  There  is  one  feature  zVz  the  ordinary  hand-mallet  that 
is  not  to  be  found  in  any  other :  the  patient  is  connected  with  the  mallet 
only  at  the  exact  momeiit  of  contact  as  the  blow  is  struck.  With  all 
other  mallets  the  patient  is  practically  connected  with  the  instruments 
behind  the  mallet  all  the  time.  This  is  especially  true  with  the  auto- 
matic. What  is  its  action  ?  The  point  is  allowed  to  rest  against  the 
filling,  and  then  pressure  is  exerted  till  a  released  spring  causes  a  blow 
to  be  struck.  Is  it  not  evident  that  the  whole  blow  is  anticipated  by 
the  patient  every  time  ?  Is  it  not  plain  that,  to  a  nervous  person,  this 
expectation  of  the  coming  stroke  must  be  maddening  ?  It  was  to  me, 
and  I  am  by  no  means  described  by  the  curious  word  "nervous," 
which  in  fact  should  read  "nerveless."  With  the  electric  and  with 
the  mechanical  mallet  it  may  be  argued  that  the  patient  is  made  to 
feel  the  mallet  only  at  the  moments  when  the  blows  are  produced,  but 
these  occur  so  frequently  that  the  patient  is  practically  connected  with 
the  instrument  all  the  time.  Besides,  the  force  which  manages  the 
hand-mallet  is  that  magnificent  machine  made  by  the  Creator,  which, 
without  being  oiled,  runs  noiselessly.  The  powers  which  control  the 
two  mallets  mentioned,  even  when  thoroughly  oiled,  make  consider- 
able noise,  and  produce  an  answering  response  from  the  suffering 
patient. 

I  think  that  the  hand-mallet  is  preferable  to  all  others.  I  depend 
upon  it  whenever  I  feel  that  there  is  necessity  for  the  very  best  at- 
tainable result.  Of  course  it  has  its  limitations.  There  are  places 
where  a  man  would  need  three  hands, — one  for  the  mallet,  one  for 
the  plugger,  and  one  for  a  mouth- mirror  with  which  to  reflect  light, 
or  with  which  to  see  the  cavity.  For  I  must  deprecate  the  habit  of 
having  an  assistant  do  malleting.     I  cannot  see  how  two  brains  can 


88  METHODS  OF  FILLING   TEETH. 

serve  as  well  as  one  in  this  instance.  Of  course  one  must  be  ambi- 
dextrous to  do  this,  but  all  dentists  should  have  the  free  use  of  both 
hands.  I  do  not  hesitate  to  use  my  engine  with  my  left  hand  as 
quickly  as  I  would  with  my  right.  Why  children  are  ever  taught  to 
acquire  the  habit  of  depending  upon  one  hand,  thus  partly  losing 
the  use  of  the  other,  is  one  of  the  mischievous  mysteries  of  civilization. 
It  is  one  of  the  ■  follies  of  fashion.  A  dentist  who  cannot  use  the  left 
hand  may  acquire  its  use  as  I  did,  by  practicing  writing  at  all  spare 
moments.  Do  not  write  as  one  does  with  the  right  hand,  but  reverse 
it ;  that  is,  begin  at  the  right-hand  side  of  the  paper  and  write  toward 
the  left,  or  what  we  would  call  backward.  This  is  because  whenever 
we  use  a  muscle  a  certain  impulse  to  the  same  end  is  sent  to  the 
fellow  of  the  opposite  side,  so  that  our  long  habit  of  writing  with  the 
right  hand  has,  to  a  certain  extent,  educated  the  muscles  of  the  other 
hand  to  the  same  purpose.  When  we  use  the  right  hand  we  begin 
on  the  left  side  and  move  toward  the  right ;  therefore,  to  get  the  same 
action  from  the  muscles  when  we  use  the  left,  we  must  work  from  right 
to  left.  In  a  short  time  one  can  learn  to  mallet  with  the  right  hand, 
and  manage  the  plugger  with  the  left.  This  is  more  satisfactory  than 
depending  on  the  assistant,  who  may  or  may  not  mallet  to  suit. 

Of  the  power  mallets,  I  prefer  the  Bonwill  mechanical,  as  being 
easier  to  manipulate  and  more  satisfactory  in  its  working.  Certainly 
there  are  no  batteries  or  motors  to  keep  in  order,  or  add  to  the 
noise.  The  stroke  is  always  under  control,  either  as  to  speed  or  force 
of  blow.  There  is  one  thing  worth  mentioning  in  this  connection. 
When  I  first  obtained  a  Bonwill  mallet,  I  did  so  only  on  trial.  I  think 
I  was  attracted  to  it  because  of  its  ingenuity  rather  than  by  any  in- 
herent merit  which  I  expected  to  find  In  it.  I  was  very  much  prejudiced 
against  such  an  instrument.  All  the  argument  which  I  have  just  used 
about  the  connection  between  the  patient  and  the  mallet,  I  had  power- 
fully before  my  mind.  I  tried  it  conscientiously,  however,  with  the 
result  that  by  alternating  between  it  and  the  hand-mallet  I  obtained 
an  expression  of  preference  from  my  patients.  I  think  fully  ninety 
per  cent,  chose  the  Bonwill.  The  others  were  of  course  those  nervous, 
or  nerveless,  individuals  to  whom  noise  becomes  an  irritant. 

Pluggers  to  be  used. — This  is  a  subject  upon  which  a  great  deal  of 
discussion  has  been  devoted,  and  I  think  largely  wasted.  The  size 
and  shape  of  a  plugger  must  depend  largely  upon  a  man's  personal 
preferences.  Instruments  with  which  one  man  operates  beautifully 
would  be  worthless  to  another.  Of  course,  certain  mechanical  princi- 
ples can  be  cited,  which  theoretically  will  prove  that  there  is  but  one 
form  of  point  that  best  condenses  gold,  but  in  practice  a  broken  instru- 
ment is  as  good  as  any,  in  the  hands  of  the  skillful.  Points  that  are  ser- 
rated, or  round,  or  flat,  or  smooth,  or  thick,  or  thin,  may  either  or  all 


CONTOUR  vs.  FLAT  FILLINGS.  89 

be  made  to  produce  good  results.  As  to  shape,  a  few  varieties  are 
convenient,  but  I  may  mention  that  when  I  first  took  the  Bonwill  I 
received  only  one  point  with  it.  I  used  that  one  point  for  a  year,  and 
though  I  have  bought  a  few  others  since,  so  as  not  to  appear  stingy,  I 
rely  upon  that  same  point  now  almost  to  the  exclusion  of  all  others.  It 
is  practically  universal  as  a  mallet-plugger.  The  young  dentist  should 
endeavor  to  get  along  with  as  i&w  instruments  as  possible,  rather  than 
with  many.  With  a  few  instruments  the  workman  is  the  master  ; 
Avith  many  he  is  the  slave,  for  he  is  powerless  as  soon  as  one  is  mis- 
laid. 


C  H  A  P  T  E  R    I V. 

The  Relative  Values  of  Contour,  and  Flat  or  Flush  Fillings — 
The  V-Shaped  Space  in  its  Relation  to  the  Gingiva — The  Re- 
storation of  Superior  Lateral  Incisors — Slight  Contours — Reg- 
ulation of  Teeth  by  Contour  Fillings — Departure  from  Original 
Form— True  Contouring — Treatment  of  Masticating  Surfaces — 
Contouring  with  Gold — With  Amalgam— With  the  Plastics  in 
connection  with  Gold  Plate — ^Use  of  Screws — Cases  from  Prac- 
tice requiring  Odd  Methods. 

To  imitate  nature  should  be  the  aim  of  every  true  artist.  Yet  the 
landscape-painter,  who  contents  himself  with  copying  what  he  sees 
spread  out  before  his  view,  would  frequently  produce  a  picture  which 
lacked  composition.  In  dentistry  the  skilled  workman  is  he  who  has 
the  eye  to  see  contour,  the  trained  fingers  to  reproduce  it,  and  the 
judgment  to  decide  wheji  ayid  where  it  should  not  be  attempted. 

The  reproduction  of  the  original  form  of  a  tooth,  which  has  beea 
partly  destroyed  by  caries,  must  be  undertaken  in  over  ninety  per 
cent,  of  the  cases  presenting.  This  being  my  opinion,  and  being  one 
contrary  to  the  teaching  and  the  practice  of  some  men  of  eminence,  I 
shall  state  some  of  the  reasons  for  my  conviction. 

It  will  scarcely  be  disputed  that  the  whole  scheme  of  the  universe 
is  a  perfect  plan.  No  improvement  upon  it  is  possible.  The  con- 
struction of  every  creature  is  accurately  adapted  to  his  intended  mode 
of  life.  Yet  it  has  been  claimed  by  some  that  the  formation  and 
structure  of  the  teeth  of  man  are  less  perfect  than  those  of  the  lower 
animals,  since  man  is  the  only  animal  who  constantly  suffers  from 
caries.  This  disease  has  been  found  in  other  animals,  but  it  cannot 
be  said  of  any  other  species  that  we  can  take  any  individual  at  ran- 
dom, and  be  almost  sure  to  discover  the  ravages  of  caries,  as  we  do  in 
man.  Consequently  we  must  admit  that  the  human  race  is  more  suscep- 
tible to  it.     That  this  is  due  to  the  formation  of  the  teeth  themselves. 


90 


METHODS  OF  FILLING   TEETH. 


or  to  their  arrangement  in  the  jaws,  however,  cannot  be  claimed, 
because  the  chimpanzee,  the  gorilla,  and  other  members  of  the  ape 
family  have  jaws  practically  similar  to  that  of  man,  and  yet  caries  is  so 
rare  with  them  that  a  jaw  with  the  teeth  showing  it  is  a  curiosity  to  be 
preserved  and  placed  in  the  glass  case  of  a  museum. 

The  probability  is  that  man  suffers  because  he  cooks  his  food,  for 
we  find  that  where  we  take  animals  unaccustomed  to  such  diet,  and 
domesticate  them,  feeding  them  upon  our  style  of  food,  they  fre- 
quently sutfer  from  caries.  The  question  then  arises,  Shall  we  alter 
the  shape  of  a  tooth  which  has  been  attacked  ?  Shall  we  depart  from 
the  standard  set  up  by  Nature,  because  of  the  fact  that  we  do  not  eat 
the  kind  of  food  for  which  we  were  designed  ?  If  we  examine  the 
dog,  we'  discover  that  with  his  pointed  teeth,  although  he  eats  from 
our  table,  he  suffers  very  rarely  from  caries.  Shall  we  decide  from 
this  that  we  may  file  the  human  tooth  into  an  approximation  of  a  cone, 
producing  such  spacing  that  the  tip  of  the  tongue  may  remove  the 
refuse  food  from  between  the  teeth?  This  is  a  serious  question, 
especially  as  the  production  of  this  V-shaped  spacing  was  once  strongly 
advocated,  and  largely  practiced.  It  is  indeed  the  custom  of  some 
dentists  to-day,  and  it  may  come  up  again  within  a  few  years,  just  as 
many  other  discarded  practices  have  been  rediscovered,  and  taught 
and  adopted,  till  their  mischievous  results  once  more  condemned  them 
to  oblivion. 

The  ^-shaped  space  will  succeed  i7i  the  human  mouthy  only  when  the 
gum  of  the  human  individual  approximates  in  density  that  which  we 
find  in  the  mouth  of  the  dog.  In  man  the  teeth  occlude  squarely,  the 
one  against  the  other.  We  grind  our  food  between  enamel-surfaces. 
With  the  dog,  except  in  the  incisive  region,  the  teeth  pass  between 
one  another,  and  bite  against  the  gum  itself.  This  gum-tissue  is  com- 
paratively thin,  and  supported  below  by  a  dense  alveolus.  Such  a 
thing  as  an  inflammation,  or  hypertrophy,  in  this  region  is  unknown. 
I  have  seen  pyorrhea  alveolaris  in  the  mouth  of  a  dog,  but  that  was 
in  the  incisive  region.  How  is  it  with  man  ?  The  gum-tissue  is 
arranged  in  a  very  different  manner.  We  find  between  all  the  teeth 
a  pedicle  extending  toward  the  incisive  edges.  This  pedicle  is  the 
thickest  part  of  the  soft  tissue,  and  therefore  least  able  to  withstand 
irritation  froTn pressure.  Any  attempt  to  chew  upon  it  will  result  in 
disease.  In  the  normal  mouth  it  is  protected  by  the  approximation  of 
the  adjacent  teeth,  which  by  touching  each  other  are  expected  to  pre- 
vent food  from  passing  between  the  teeth,  and  impinging  upon  the 
gingiva.  I  argue  therefore  that  we  cannot  allow  ourselves  to  copy  the 
dog,  because  while  we  may  give  man  the  dog-shaped  tooth,  we  cannot 
assure  hiTn  a  resistant  gum-tisszie  betzveen  the  teeth,  zvhich  will  with- 
stand the  crowding  of  food  against  it,  as  occurs  with  the  lower  animal. 


THE  V-SHAPED  SPACE.  9 1 

In  conditions  of  disease  where  pyorrhea  alveolaris  has  been  pres- 
ent, we  have  been  taught,  and  well  taught,  that  until  we  can  produce 
rigidity  of  the  teeth,  we  cannot  hope  to  see  the  disease  cured  or  even 
temporarily  controlled.  Why  is  this  ?  Because  as  long  as  the  teeth 
are  readily  movable,  the  soft  tissue  will  be  in  a  constant  condition  of 
irritation  due  to  such  motion.  If  this  be,  and  it  is  true,  should  we  not 
pause  before  producing  or  leaving  spaces  between  teeth  ?  As  soon  as 
a  space  is  made,  do  we  not  destroy  the  integrity  of  the  abutments  in 
the  arch,  and  so  make  mobility  of  all  the  teeth  more  possible 
than  before  ?  This  is  especially  true  of  the  two  teeth  on  either  side  of 
the  space.  Whenever  food  is  chewed  in  that  region,  it  is  packed  be- 
tween the  slanting  planes,  and  acts  as  a  wedge  to  drive  the  teeth  apart. 
Not  infrequently  this  results  in  a  loosening  of  the  two  teeth,  accom- 
panied coincidently  by  an  inflammation  of  the  gingiva.  This  inflam- 
mation goes  on  till  a  suppurative  stage  presents  ;  then  there  may 
occur  hypertrophy,  and  often  pyorrhea  directly  results.  I  have  noted 
mouths  where  several  teeth  were  affected  with  this  dreadful  disease, 
and  then  have  found  that  the  teeth  most  involved  were  two  between 
which  the  V-shaped  space  had  been  made.  I  have  no  hesitation  in 
saying  that  in  these  cases  the  pyorrhea  was  first  caused  as  I  have 
specified,  and  that  subsequently  the  neighboring  teeth  suffered  by  in- 
fection. Thus  the  dentist  who  filled  the  space  invited,  and  I  may  say 
induced,  pyorrhea.  Of  course  these  are  extreme  cases,  and  there  are 
instances  where  the  V  space  has  been  entirely  successful ;  but  in  all 
cases  that  have  come  under  my  observation,  and  they  have  been  very 
few,  I  have  noted  that  the  gum-tissue  was  dense  and  tightly  drawn 
over  the  alveolus,  the  pedicles  between  the  teeth  being  of  a  carti- 
laginous firmness,  short,  and  tough. 

In  brief,  my  chief  reason  for  advocating  contour  fillings,  aside  from 
any  consideration  of  cosmetic  effects,  is  that  to  leave  a  space,  or  to 
form  one,  between  two  teeth,  is  liable  to  result  in  a  loosening  of  the 
teeth,  or  a  diseased  condition  of  the  gingiva.  In  the  latter  case,  caries 
will  almost  certainly  reappear  along  the  gingival  margin  of  the  cavity, 
and  undermine  the  filling. 

The  production,  then,  of  a  perfect  contour,  is  the  most  important 
element  in  the  successful  filling  of  teeth.  A  novice  may  soon  be  taught 
to  stop  a  small  cavity  which  is  surrounded  by  strong  walls.  To  insert 
a  contour  filling,  of  such  a  form  that  beauty,  usefulness,  and  strength 
shall  each  be  attained  in  the  highest  relation  to  the  conditions  present- 
ing, requires  a  skillful  manipulation,  a  knowledge  of  tooth-form,  and 
a  mature  judgment,  which  only  experience  can  give.  I- can  only  hope 
to  direct  attention  in  the  proper  channel.  No  theorizing  can  give  the 
student  such  attainment. 

In  every  case  which  presents,  the  question  will  arise.  Can  the  original 


92  METHODS  OF  FILLING   TEETH. 

form  be  reproduced,  without  danger  of  future  failure  ?  This  requires 
often  a  keen  knowledge  of  the  mechanical  arrangement  of  the  cavity 
for  the  retention  of  the  filling,  of  the  probable  strength  of  the  special 
tooth  under  consideration,  of  the  force  of  leverage  which  under  masti- 
cation the  filling  will  exert  upon  its  anchorage,  and  of  the  amount  of 
usage  which  the  particular  patient  will  give  to  it.  There  are  men  who 
chew  with  such  energy  that  they  not  only  wear  out  their  teeth  early 
by  abrasion,  but  the  best  gold  filling  will  become  roughened  rapidly 
in  their  mouths.  In  such  cases  it  would  be  folly  to  attempt  an  exten- 
sive contour  with  doubtful  anchorage  ;  whereas  in  the  jaw  of  a  refined 
and  delicate  woman,  the  experiment  might  be  made  with  much  safety. 
The  lateral  incisor  of  the  superior  jaw  offers  the  greatest  problem  in 
contour,  but  fortunately  it  is  a  tooth  so  variable  in  shape  that  we  may 
be  enabled  in  almost  any  case  to  so  fashion  the  filling  that  it  will  be 
durable  and  at  the  same  time  sightly  ;  that  is,  if  compelled,  we  may 
produce  a  contour  which  is  of  good  form,  though  not  similar  to  the 
■original  structure. 

Fig.  65.  Fig.  66.  Fig.  67. 


00 


Fig.  65  shows  a  lateral  incisor  with  a  cavity  which  is  often  puzzling. 
Where  the  pulp  has  been  removed,  we  may  obtain  such  good  anchorage 
in  the  upper  part  of  the  cavity,  packing  the  gold  well  into  the  canal  if 
need  be,  that  we  would  have  no  hesitation  in  producing  a  full  contour 
as  seen  in  Fig.  66.  But  suppose  that  the  pulp  be  alive,  and  despite 
the  ravages  of  caries  sufficiently  well  covered  by  dentine  to  render  its 
salvation  assured  ?  It  would  be  most  reprehensible  to  devitalize  it. 
Yet  to  attempt  to  obtain  an  anchorage  which  would  retain  such  a  con- 
tour as  shown  in  Fig.  66  would  in  most  cases  be  impossible,  and  even 
where  attained,  we  would  be  likely  to  approach  the  pulp  so  closely  at 
some  point  that  it  would  be  liable  to  die  subsequently.  I  will  give  a 
case  of  this  character  from  practice,  which  will  be  instructive.  But 
first  let  me  dispose  of  this  lateral  incisor  with  its  living  pulp.  We  may 
fill  the  tooth,  preserve  the  life  of  the  pulp,  and  produce  a  presentable 
and  durable  contour,  by  resorting  to  a  screw,  and  shaping  as  shown 
in  Fig.  67.  The  distal  corner  of  the  lateral  incisor  is  often  a  fairly  sharp 
angle,  but  it  is  more  often  a  curve,  and  sometimes  as  much  curved 
as  shown  in  the  last  figure.  If  Figs.  66  and  67  be  compared,  it  will  be 
seen  that  in  the  former  the  length  of  the  gold  along  the  incisive  edge 


RESTORA  TION  OF  INCISORS. 


9? 


produces  a  strong  leverage,  which  during  mastication  would  operate 
to  force  the  filling  out  of  the  cavity.  Where  the  anchorage  therefore 
is  slight,  it  will  be  safer  to  adopt  the  second  form,  or  as  much  of 
an  approximation  to  it  as  judgment  shall  direct,  for  the  leverage  is 
almost  annihilated  by  the  curved  line,  while  we  still  retain  a  sem- 
blance of  tooth-form.  Where  the  tooth  of  the  opposite  side  is  so 
markedly  ditferent  as  to  make  too  decided  a  contrast,  there  might  be 
no  harm  in  slightly  altering  it  so  as  to  produce  harmony. 

To  come  to  the  case  from  practice  alluded  to.  The  patient  was 
a  married  woman  about  twenty-five  years  of  age,  and  decidedly 
anemic.  She  was  excessively  nervous,  and  her  teeth  hypersensitive. 
The  history  given  to  me  was  that  the  two  teeth  which  she  wished  me- 
to  fill  had  already  been  filled  seven  times,  each  time  with  gold,  and 
all  had  failed.  They  were  a  central  and  a  lateral  incisor.  The  first 
examination  showed  two  crumbling  gold  fillings,  of  very  poor  shape 
and  leaking  badly.  They  were  readily  tipped  out  with  an  excavator, 
and  the  cavities  were  most  uninviting.  The  central  incisor  seemed  to 
be  the  more  difficult,  and  therefore  was  undertaken  first.     Fig.  68 


Fig.  68. 


Fig.  69. 


Fig.  70. 


Fig.  71. 


gives  the  condition  of  the  tooth  seen  from  the  palatal  aspect,  where 
the  loss  of  tissue  was  most  apparent.  After  crowding  the  gum  away 
by  packing  cotton  against  it  for  several  days,  so  that  the  dam  could 
be  forced  above  the  gingival  border,  I  prepared  the  cavity  as  seen  in 
Fig.  69,  making  a  slight  groove  immediately  within  the  border  at  all 
points,  and  extending  one  or  two  horns  of  the  cavity  upward,  avoid- 
ing the  pulp.  As  will  be  observed,  this  practically  surrounded  the  pulp 
with  gold  between  which  and  it  there  was  but  little  dentine.  To  make 
all  more  sure,  I  used  the  method  previously  described,  covering  the 
cavity  with  oxyphosphate,  before  inserting  the  first  pieces  of  gold.  I 
then  filled  the  tooth  so  that  it  appeared  as  shown  in  Figs.  70  and  71, 
which  give  the  palatal  and  labial  aspects.  Observe  that  very  little  gold 
shows  from  the  labial  point  of  view,  and  that  though  the  anchorage 
here  was  very  poor,'  it  was  probably  sufficient,  because 'the  leverage 
is  very  slight,  there  being  but  little  gold  along  the  incisive  edge.  I 
felt  quite  elated  at  my  success  in  this  most  difficult  case,  and  turned 
to  the  lateral  incisor  with  considerable  assurance.     Here  I  found  so 


94  METHODS  OF  FILLING  TEETH. 

much  decay  that  I  was  compelled  to  destroy  the  pulp,  which  was 
exposed  badly.  This,  however,  gave  me  a  better  anchorage,  and  I 
anticipated  no  trouble.  Immediately  after  the  pulp  was  removed,  the 
patient  reported  continuous  and  excessive  pain  at  night.  I  did  every- 
thing to  allay  the  mysterious  suffering,  and  it  was  not  till  a  week  later 
that  she  was  able  to  assure  me  positively  that  it  was  the  ce7itral  incisor 
which  ached,  and  not  the  lateral  incisor  as  we  both  had  supposed.  I 
then  reluctantly  concluded  that  the  presence  of  so  much  gold  so  near 
the  pulp,  even  protected  by  the  phosphate,  had  resulted  in  a  pulpitis. 
I  drilled  into  the  palatal  side,  entering  the  pulp-chamber,  and  after 
considerable  hemorrhage  removed  the  pulp  without  resorting  to 
arsenical  treatment.  I  am  as  positive  as  one  can  be  that  this  pulp  was 
not  exposed  even  minutely,  as  we  understand  the  term  exposure. 
That  it  was  very  nearly  approached  there  was  no  doubt,  and  it  is 
plain  now  that  it  would  have  been  better  to  destroy  it,  thus  obtaining 
a  stronger  anchorage  for  the  filling  and  rendering  the  work  far  less 


Fig.  72.  Fig.  73.  Fig.  74 


•difficult.  It  was  a  case  where  a  screw  would  have  rendered  the  opera- 
tion excessively  tedious,  because  of  the  position  of  the  cavity,  which 
was  almost  out  of  sight.  It  was  a  cavity  the  difficulties  of  which  can- 
not be  appreciated  from  a  description,  even  accompanied  by  the  best 
illustrations,  and  I  introduce  it  only  to  show  that  the  immediate 
approach  of  gold  to  a  pulp  is  a  menace  to  the  life  of  that  organ.  The 
phosphate  did  not  prevent  the  disaster,  because  it  was  removed  from 
all  the  grooves  and  deepest  parts  of  the  cavity,  that  the  filling  might 
be  more  secure,  and  it  was  in  these  places  that  the  gold  approached 
the  pulp  nearest.  After  the  removal  of  the  pulp  all  pain  disappeared, 
proving  that  this  was  the  offender. 

Where  the  approximal  surface  of  an  incisor  has  been  only  slightly 
lost,  many  men,  possibly  because  they  lack  a  knowledge  of  tooth- 
form,  make  no  effort  to  restore  contour.  The  eye  of  the  true  artist 
finds  no  difficulty  in  designating  what  was  the  original  form  of  a  given 
decayed  tooth,  for  he  judges  from  what  is  left  of  the  lines,  and  by 
continuing  these  in  his  imagination  has  in  his  mind  a  picture  of  what 
existed  before  the  destruction.  In  Fig.  72  we  observe  a  central  in- 
cisor the  approximal  portion  of  which  has  been  lost  by  caries.  I  have 
seen  many  cases  of  this  character  filled  so  as  to  appear  as  seen  in  Fig. 


TRUE  CONTOURING.  95 

73,  and  even  filled  flat,  so  that  no  gold  at  all  was  visible  from  the 
labial  aspect.  There  may  be  instances  where  such  a  course  would  be 
permissible,  and  I  am  not  altogether  discouraging  the  practice  of  not 
showing  much  gold.  The  point  that  I  would  bring  out  is  that  Fig.  73 
does  not  restore  the  original  form  of  Fig.  72.  The  eye  of  the  artist 
must  see  at  a  glance  that  the  lines  of  the  filling  in  Fig.  73  indicate  a 
different  form  to  that  shown  in  Fig.  74.  The  production  of  these  very 
slight  contour  fillings  always  indicates  the  hand  of  a  master.  When 
I  see  a  delicate  line  of  gold  showing,  which  just  supplies  the  lost  tissue, 
I  inquire  the  name  of  the  dentist  and  place  a  mark  to  his  credit.  I  do 
more  than  that,  for  where  he  is  resident  of  a  different  city,  I  place 
him  on  my  list  of  those  to  whom  I  refer  patients  of  mine  who  may  be 
traveling. 

The  restoration  of  these  slight  losses  along  the  approximal  surfaces 
brings  me  to  the  consideration  of  a  subject  which  I  have  seldom  seen 
discussed.  In  crowded  jaws  we  sometimes  see  two  teeth,  let  us  say 
the  superior  central  incisors,  each  decayed  along  the  mesial  surface, 

Fig.  75.  Fig.  76. 


QO 


and  yet  in  close  contact.  A  glance  seems  to  indicate  that  they  have 
actually  been  pressed  into  each  other.  Such  a  condition  is  shown  in 
Fig.  75.  What  has  occurred  here  ?  As  teeth  have  erupted  posterior 
to  this  region,  the  decay  along  these  surfaces  has  allowed  the  central 
incisors  to  yield  and  be  crowded  together.  If  they  are  filled  with  flat 
fillings,  as  in  Fig.  72,  we  do  not  show  gold,  but  we  leave  the  teeth  in 
their  irregular  and  unsightly  position.  These  teeth  can  be  regulated, 
and  retained  in  their  proper,  erect  position  by  simply  wedging  them 
far  enough  apart  to  permit  a  restoration  of  contour  with  gold.  They 
can  be  made  to  appear  as  in  Fig.  76,  which  is  assuredly  more  pleasing. 
To  the  minds  of  many  dentists,  the  word  contour  seems  to  convey 
an  idea  only  of  the  restoration  of  shape  so  far  as  concerns  that  part 
of  the  tooth  which  is  exposed  to  view.  I  have  seen  approximal  fill- 
ings beautiful  in  form  and  finish,  if  looked  at  from  the  labial  view, 
but  which  at  the  palatal,  incisive,  or  approximal  aspects  by  no  means 
restored  even  an  approach  to  contour.  Fig.  77  shows  such  a  piece 
of  work,  all  the  imperfections  of  which  are  easily  seen  if  we  examine 
from  the  palatal  side.  We  note  that  the  palatal  concaved  surface  has 
not  been  reproduced,  that  the  approximal  surface  is  not  rounding  and 
full,  and  that  the  incisive  edge  is  not  square,  but  rather  sharpened  to 


96  METHODS  OF  FILLING  TEETH. 

a  thin  edge.     When  I  see  this  sort  of  work,   I  judge  that  the  dentist 
is  aiming  chiefly  to  please  the  eye  of  his  patient,  rather  than  to  pro- 
^  duce  a  perfect  contour,   if  indeed  he  has 

the  skill  to  fashion  what  he  evidently  has 
W,,  :i|  not  conceived.  To  restore  by  coyitouring 
/~^\_-''^  /?z^(3:7Zj"  to  restore  form  froin  all  points  of 
f  view.  It  is  as  essential  at  one  part  as  at 
l^^^mm  any  other,  for  the  cosmetic  effects  are  of 
^^BP^  the  least  importance,  though  to  be  highly 
^^Wf  considered.     In  other  words,   we   do  not 

^/  restore  contour  for  beauty,  but  for  utility. 

Thus  we  come  to  the  grinding-surfaces 
of  bicuspids  and  molars.  Shall  we  feel  bound  to  reproduce  the  sulci 
when  we  form  almost  the  entire  surface  with  our  fiUiiig-material  ?  In 
bicuspids  it  is  usually  both  advisable  and  necessary  to  do  this,  at 
least  to  a  considerable  extent.  There  is  no  object  in  burring  out  two 
deep  pits  such  as  are  found  in  the  normal  crowns,  but  as  the  occlu- 
sion in  this  region  is  usually  very  accurate,  the  cusps  of  the  lower 
opposing  teeth  biting  squarely  and  sharply  into  the  sulci  of  their 
antagonists,  it  becomes  essential  in  forming  the  filling  to  remember 
this,  and  to  accommodate  the  form  to  the  requirements.  In  molars, 
I  think,  that  a  middle  ground  is  safest.  We  should  not  make  an  ex- 
tensive gold  filling  and  leave  it  absolutely  flat,  for  we  thus  offer  a 
very  poor  masticating  surface.  At  the  same  time,  to  attempt  to 
carve  out  an  exact  reproduction  of  sulci  as  seen  in  a  real  tooth  would 
not  only  be  time  unnecessarily  spent,  but  the  result  would  be  really 
bad.  I  am  certain  that  gold  thus  carved  will  not  be  as  durable  as 
where  a  mere  approximation  is  aimed  at.  Such  depressions  as  may 
be  produced  with,  fairly  large- sized  gold-cutting  burs  will  leave  a  sur- 
face sufficiently  cusped  for  service  without  making  it  difficult  to  pro- 
duce a  perfect  polish,  which  is  essential  to  durability. 

This  brings  us  to  a  consideration  of  cases  where,  by  the  attrition  of 
energetic  mastication,  a  patient  presents  with  a  complete  set  of  teeth, 
all  of  them  having  lost  about  one- third  of  their  original  length.  Is  it 
necessary  here  to  attempt  a  complete  contour  ?  I  think  not.  Such  a 
person  has  gradually  become  accustomed  to  having  the  jaws  close 
together  more  than  when  the  teeth  were  perfect,  therefore  there  is  no 
discomfort  to  him  because  of  the  loss  in  length.  The  necessity  for 
interfering  at  all  arises  from  the  desire  to  prevent  further  destruction. 
In  tipping  a  whole  set  of  teeth  with  gold  in  this  class  of  cases,  it  is 
only  necessary  to  build  on  a  sufficient  thickness  of  gold,  so  that  what 
is  placed  may  be  strong  enough  to  prove  resistant.  If  a  molar  on 
each  side  be  treated  in  this  way  at  the  first  sitting,  the  mouth  will  be 
opened  a  trifle  all  round,  and  the  other  teeth  in  turn  may  be  built  up 


CONTOUR  IN  RELATION  TO  INTERPROXIMAL  SPACES.    97 

to  suit  the  new  occlusion.  In  the  incisors  it  will  be  found  that  the 
cutting- edges  are  quite  broad,  so  that  there  is  little  difference  between 
them  and  the  cuspids  and  bicuspids.  No  attempt  should  be  made  to 
produce  cutting-edges  similar  to  what  was  in  the  first  place.  What  is, 
is  what  the  man  is  accustomed  to,  and  he  will  be  happier  if  his  teeth 
are  left  to  him  as  they  are.  Of  course  the  filling  following  the  lines 
of  contour  may  slightly  narrow  the  edges,  but  this  should  not  be 
carried  to  an  extreme. 

Many  cases  will  occur  in  every  practice  where  any  attempt  at  con- 
tour will  be  impossible  because  of  the  fact  that  the  position  of  the 
tooth  has  changed  since  the  destructive  process  began.  Often  we 
see  teeth  lifted  from  their  sockets,  as  the  decay  advances,  so  that 
an  occlusion  is  effected.  To  build  up  such  a  tooth  to  original  pro- 
portions would  be  to  open  the  mouth,  by  making  that  the  only  tooth 
which  strikes.  In  these  and  other  similar  conditions  judgment  must 
have  sway,  and  direct  the  hand.  There  will  be  many  cases,  too, 
which  will  allow  only  a  flat  filling,  and  in  some  a  flat  filling,  while 
serving  every  purpose,  will  entirely  alter  the  original  form  of  the  tooth. 
Fig.  78  shows  an  approximal  view  of  a  bicuspid,  the  palatal  cusp  and 

Fig.  78.  Fig.  78  a.  Fig.  78  b. 


»(i. 


side  of  which  have  been  completely  lost.  In  such  a  case,  if  the  pulp 
is  dead,  a  complete  contour  should  be  attempted,  anchorage  in  the 
root-canal  making  this  perfectly  safe.  The  result  is  shown  in  Fig.  78  a, 
the  extreme  edge  of  the  remaining  natural  cusp  being  ground  off  to 
allow  a  masticating  surface  of  gold  only.  Where  the  pulp  is  alive  a 
totally  different  course  should  be  followed,  as  shown  in  Fig.  78  b. 
Here  we  see  that  a  flat  filling  has  been  resorted  to,  the  tooth  assum- 
ing the  form  of  a  cuspid  rather  than  of  a  bicuspid.  In  this  case  the 
tip  of  the  natural  cusp  is  not  removed,  for  with  the  shape  in  which 
the  tooth  is  to  be  left  mastication  will  not  be  a  great  menace  to  it, 
as  it  will  where  a  mass  of  gold  is  inserted  so  as  to  reproduce  the 
palatal  cusp,  which  acts  as  a  powerful  lever  to  shatter  the  standing 
wall. 

Contour  in  Relation  to  Interproximal  -Spaces. 

Thus  far  I  have  considered  contour  filling  rather  from  the  cosmetic 
aspect,  and  as  opposed  to  that  system  which  intentionally  produces 
permanent  spaces  between  the  teeth.     It  is  of  equal  importance  to 

7 


98  METHODS  OF  FILLING  TEETH. 

understand  where  a  departure  from  restoration  of  original  shape  may 
become  requisite  in  order  to  perfectly  protect  the  easily  injured 
gingiva.  In  a  normal  mouth,  the  teeth  being  of  typical  form  and 
placed  regularly  in  the  arch,  the  rule  is  safe  which  directs  that  the 
contour  shall  accurately  restore  the  original  tooth  form,  in  all  cases 
where  the  gingiva  is  normal  and  healthy.  But  exceptional  cases  will 
occur  in  all  practices  where  a  departure  from  this  rule  will  become 
necessary  ;  then  experience  must  direct  what  form  will  best  conserve 
the  tooth  and  assure  the  comfort  of  the  patient. 

Where  approximal  cavities  have  been  neglected,  the  depredation  is 
so  great  that  a  lodging-place  is  afforded  for  food,  and  the  normal 
protection  of  the  gingiva  is  removed,  so  that  ultimately  the  gingiva 
suffers.     We  find  either  hypertrophy,  or  atrophy. 

Where  hypertrophy  of  the  gingiva  occurs  in  connection  with  teeth 
of  normal  shape  and  position,  the  restoration  of  original  contour  is  a 
safe  reliance.  The  gingiva,  being  protected  by  the  filling  as  well  as 
it  was  by  the  tooth  prior  to  the  attack  of  caries,  quickly  resumes  a 
healthy  tone,  and  finally  heals.  But  if  from  malformation  or  mal- 
position of  one  or  both  teeth  the  gingiva  was  not  properly  protected 
when  the  teeth  were  sound,  a  restoration  of  original  contour,  how- 
ever well  filled  the  tooth  may  be  fro'm  a  mere  mechanical  point  of 
view,  would  not  bring  about  a  healthy  condition  of  the  gingiva. 
Originally,  when  in  a  state  of  health,  it  may  have  withstood  the  im- 
pact of  food  against  it,  through  the  space  which  nature  had  failed  to 
close  ;  but  when  diseased  it  will  not  tolerate  the  continued  irritation 
occasioned  by  the  presence  of  food  packed  between  the  teeth,  and 
consequently  will  not  recover  its  healthy  tone. 

Definite  clinical  features  will  be  observable.  The  patient  will  be 
troubled  by  the  lodgment  of  food  in  the  unprotected  space,  and  will 
complain  of  this  and  report  that  his  "teeth  bleed"  when  he  uses  a 
toothpick,  or  floss  silk.  Of  course  it  is  the  gingiva  which  bleeds, 
which  indicates  that  the  hypertrophy  persists.  Subsequently 
caries  supervenes  along  the  gingival  border  of  the  filling,  which,  if 
neglected,  will  loosen  the  filling  by  undermining  it,  thus  enlarging  the 
cavity,  and  perhaps  affecting  the  pulp,  in  cases  where  living  teeth  are 
involved.  If  this  recurrence  of  caries  is  discovered,  where  the  gin- 
giva has  remained  in  a  state  of  hypertrophy,  the  entire  filling  must  be 
removed  and  replaced  by  one  which  will  protect  the  gingiva.  To 
patch  such  a  filling  is  worse  than  reprehensible. 

In  cases  where  the  gingiva  adjacent  to  an  approximal  cavity  is 
found  to  be  atrophied,  the  original  form  of  the  tooth  must  be  modi- 
fied in  making  the  restoration.  It  would  perhaps  be  more  accurate 
to  say  that  the  point  of  contact  with  the  neighboring  teeth  must  be 
changed. 


CONTOUR  IN  RELATION  TO  INTERPROXIMAL  SPACES.  99 

The  general  principle  involved  is  as  follows:  In  a  normal  state  the 
interproximal  space  is  approximately  triangular,  the  base  of  the 
triangle  being  the  alveolar  process,  and  the  sides  the  slanting  surfaces 
of  the  teeth.  To  fully  comprehend  this  it  will  be  well  for  the  student  to 
examine  a  skull,  which,  being  denuded  of  soft  tissues,  more  fully  dis- 
closes the  actual  form  of  the  interproximal  spaces.  In  the  living 
mouth  the  base  of  this  triangular  space  is  covered  with  the  soft  gum- 
tissue,  which  depends  in  a  pedicle  between  the  teeth,  almost  filling  the 
space.  Indeed,  the  only  space  remaining  at  all  is  due  to  the  fact  that 
nature  deals  in  curved  lines,  and  the  gingiva  consequently  is  rounded 
at  the  apex,  thus  leaving  a  very  tiny  space  between  it  and  the  point 
of  contact  between  the  adjacent  teeth. 

Caries  attacks  the  teeth  where  they  touch,  and  almost  as  soon  as 
actual  cavities  exist  the  barrier  disappears,  and  therefore  no  longer 
shields  the  gingiva.  Food  is  packed  between  the  teeth,  and  whether 
it  be  allowed  to  remain  or  be  removed  with  a  toothpick,  a  constant 
irritation  of  the  gingiva  is  consequent  upon  the  loss  of  its  protective 
barrier.  In  the  anemic  individual  the  tissues  are  liable  to  inflamma- 
t  on  and  its  attendant  evils  ;  more  commonly  there  is  a  gradual, 
almost  imperceptible,  wasting  of  the  gingiva,  often  termed  a  recession. 
It  is  this  condition  which  I  term  atrophy.  We  have  seen  that  there 
was  no  space  prior  to  the  attack  of  caries.  The  interproximal  space 
was  filled  with  gum-tissue.  It  must  be  equally  obvious  that  after 
this  gum-tissue  has  receded,  or  atrophied,  if  the  cavities  be  filled 
so  that  the  teeth  resume  their  normal  form,  a  space  must  remain 
between  the  teeth,  because  there  is  no  longer  the  original  gingiva 
to  occupy  it.  Hence,  in  the  presence  of  atrophied  or  receded 
gingiva,  a  modification  of  the  original  contour  will  produce  the  best 
result,  and  this  modification,  generally  stated,  would  be  of  such  shape 
as  would  result  in  leaving  no  lodging-place  for  food.  Thus  more 
specifically  the  contact  point  must  be  placed  nearer  the  gum  ;  in  fact, 
if  possible,  it  should  be  as  near  to  the  receded  gum  as  the  original 
contact  point  was  to  the  original  gingiva. 

This  point  may  be  more  clearly  shown  by  illustration,  in  connec- 
tion with  which  I  may  also  demonstrate  my  meaning  when  I  speak 
of  the  failure  of  nature  to  afford  proper  protection  to  the  gingiva  even 
prior  to  the  advent  of  caries.  Fig.  79  presents  a  condition  not  infre- 
quent. The  illustration  is  diagrammatical,  and  depicts  cross-sections 
of  first  and  second  superior  molars.  The  upper  half  of  the  figure 
shows  a  horizontal  section  across  the  crown  at  the  point  of  contact, 
which  it  is  to  be  observed  is  quite  toward  the  buccal  aspect.  The 
two  teeth  differ  in  shape,  one  being  rather  square,  while  the  other 
approximates  a  triangle.  Because  of  this  we  find  a  diverging  space, 
increasing  in  width  toward  the  palatal  aspect.     The  lower  portion  of 


lOO 


METHODS  OF  FILLING  TEETH. 


the  figure  shows  a  vertical  section  through  the  sa'me  teeth,  and  we 
may  note  that  the  point  of  contact  is  high  up  toward  the  masticating 
surfaces,  while  the  line  drawn  across  indicates  the  gum-margin,  and 
shows  that  the  gingiva  almost  fills  the  interproximal  space. 

In  Fig.  80  we  see  the  same  teeth,  after  one  has  been  attacked 
by  caries.  The  gingiva  is  still  healthy  and  fills  the  interproximal 
space.  It  is  evident  now  that  food  must  be  packed  against  it  during- 
mastication,  while  the  cavity  affords  a  lodging-place  which  will  retain 
it,  unless  removed,  thus  bringing  either  irritation  from  the  presence 
of  this  fermenting  debris,  or  else  almost  equal  disturbance  from  the 
prodding  of  a  toothpick.  If  neglected  the  result  must  be  disease 
in  some  form — hypertrophy  or  atrophy.  If  the  cavity  can  be  filled 
while  the  gingiva  is  still  healthy  and  unchanged  in  shape,  nothing 
can  be  better  than  to  restore  the  original  contour,  so  that  the  filled 
tooth  would  assume  the  same  shape  as  the  sound  tooth  in  Fig.  79,, 
all  healthy  relations  being  restored  and  maintained. 


Fig  79. 


Fig.  80. 


If,  however,  the  cavity  is  neglected  until  there  is  considerable  re- 
sorption of  the  gingiva,  as  in  Fig.  81,  and  the  original  contour  is 
then  restored,  the  result  would  be  as  shown  in  Fig.  82.  Examina- 
tion of  the  vertical  section  shows  that  the  gum  having  receded,  as 
indicated  by  the  line  which  crosses  the  figure,  the  restoration  of  origi- 
nal contour  leaves  a  considerable  space  between  the  teeth.  True,  we 
have  a  contact,  which  may  be  absolute  ;  nevertheless  food  will  readily 
be  forced  into  this  space  during  mastication.  The  explanation  is 
readily  found  by  examination  of  the  horizontal  section,  which  shows 
us  that  the  restoration  of  original  lines  reproduces  the  triangular 
shape  of  the  teeth,  and  we  have  the  divergent  space  with  contact 
only  toward  the  buccal  side. 

The  best  method  of  procedure  is  shown  in  Fig.  83.  The  horizontal 
section  shows  that  the  palatal  wall  has  been  trimmed  away,  so  that  it 


CONTOUR  IN  RELATION  TO  INTERPROXIMAL  SPACES.    lor 

may  be  restored  in  a  form  which  will  aid  in  closing-  this  dangerous 
space,  and  the  filling  when  finished  does  better  close  the  space  because 
extended  beyond  the  original  lines,  so  that  the  filled  tooth  more 
nearly  assumes  the  circumferential  shape  of  its  neighbor,  and  is 
square  now  rather  than  round.  The  vertical  section,  seen  in  the  lower 
half  of  Fig.  83,  shows  that  the  contact  point  is  placed  lower  down, 
and  that  there  is  now  a  very  broad  contact  with  little  space  above  the 
gingiva. 

Fig.  81.  Fig.  82. 


This  is  the  rule,  but  it  will  not  always  be  possible  to  follow  it  to  the 
extreme  here  indicated.  All  modifications  which  approach  this  aim — 
viz,  the  closing  of  the  space  and  the  protection  of  the  gingiva  during 
mastication — will  be  in  the  right  direction.  Where  it  is  not  prac- 
ticable to  carry  the  contact  point  as 
near   to   the  gingiva  as  shown  in   the  I^ig.  83. 

vertical  section  (Fig.  83),  it  will  still  be 
wise  to  have  as  much  contact  as  may 
be  attainable  through  from  buccal  to 
palatal  sides,  as  in  the  horizontal  section 
(Fig.  83). 

The  general  principles  here  involved 
are  equally  applicable  in  all  parts  of  the 
mouth  ;  they  do  not  apply  solely  to  the 
molars,  though  they  have  been  chosen 
as  most  readily  serving  in  the  demon- 
stration by  illustrative  figures.  For  ex- 
ample, with  the  central  incisors,  too  often  we  see  corners  restored, 
the  contour  being  quite  full  at  the  labial  aspect,  and  the  contact 
being  apparently  correct.  But,  viewed  from  the  palatal  surfaces,  it 
is  seen  that  there  is  practically  no  contour,  the  fillings  slanting 
away  from  the  contact  toward  the  palatal  margin  almost  in  a  straight 
line.    This  leaves  exactly  the  same  V-shaped  space  as  is  shown  in  the 


I02  METHODS  OF  FILLING  TEETH. 

upper  half  of  Fig.  82,  though  not  so  apparent  as  in  the  larger, 
squarer  teeth,  the  molars.  Of  course,  the  evil  results  would  be 
similar. 

Where  the  gum  has  receded  in  the  incisor  region,  the  contact  point 
should  be  removed  nearer  to  the  gum-line,  and  the  contour  should 
be  as  full  as  possible  through  the  tooth  labiopalatally. 

The  extreme  contour  and  extensive  planes  of  contact  here  advised, 
in  teeth  which  occupy  normal  positions,  must  be  decided  upon  with 
the  most  conservative  judgment  in  the  presence  of  abnormal  condi- 
tions. Two  such  will  constantly  recur  in  practice  to  harass  the 
operator.  First,  where,  because  of  extraction,  undue  separation 
between  the  remaining  teeth  exists.  Where  this  is  not  too  extreme, 
and  especially  where  both  teeth  adjacent  to  the  space  require  filling, 
it  is  often  possible  to  overbuild  the  contour  so  that  the  two  fillings 
touch,  and  thus  bridge  over  and  protect  the  already  diseased  gingiva. 

The  most  troublesome  of  this  class  of  cases  is  where,  the  third 
molar  having  been  removed,  the  second  has  moved  back,  leaving  the 
troublesome  space.  Here  it  is  useless  to  attempt  the  operation  unless 
the  occlusion  assures  the  dentist  that  the  second  molar  will  not  move 
still  farther  away  from  its  neighbor.  Often  the  only  remedy  is  to 
unite  the  two  teeth  with  a  single  filling. 

The  second  class  of  cases  is  where  undue  spacing  has  been  made 
by  the  unrighteous  use  of  a  file  in  the  hands  of  a  reckless  dentist. 
Methods  of  Producing  Contour  Fillings. 

Gold. — When  attendant  circumstances  do  not  contraindicate  its 
use,  gold  undoubtedly  will  give  the  greatest  satisfaction  where  any 
considerable  portion  of  a  tooth  must  be  reproduced.  I  have  knowa 
men  who  have  claimed  that  they  could  make  a  permanent  contour 
with  ^c?z-cohesive  gold.  I  do  not  doubt  that  such  men  do  what  they 
claim,  but  these  individuals  are  very  rare.  Therefore  I  advise  the 
beginner  to  depend  upon  cohesive  gold  when  his  filling  must  extend 
beyond  cavity-borders.  Moreover,  I  would  suggest  that  he  obtain 
gold  as  cohesive  as  it  can  be  viade. 

There  are  certain  methods  of  manipulating  gold,  essential  when 
contour  is  to  be  reproduced,  which  may  not  be  so  in  ordinary  cavities. 
For  example,  I  have  said  that  a  filling  might  be  made  hollow,  pro- 
vided it  touched  the  walls  at  all  points.  This  would  be  a  grand  error 
in  a  contour  filling.  It  has  been  stated  by  some  that  a  large  cavity 
may  be  well  filled  with  crystal  gold,  the  lower  portion  being  only 
partly  condensed,  provided  the  upper  third  be  made  solid.  However 
this  may  be  in  ordinary  work,  it  is  not  to  be  thought  of  in  contouring. 
The  rule  must  be  that  in  placing  a  contour  filling,  every  piece  of 
gold,  from  the  very  first  to  the  very  last  pellet,  must  be  thoroughly 
condensed,  and  each  and  every  pellet  should  display  perfect  cohesion. 


METHODS  OF  PRODUCING  CONTOUR  FILLINGS.        103 

To  take  up  these  two  points  separately  for  a  moment :  Let  us  suppose 
an  ordinary  cavity  with  surrounding  walls  ;  it  is  half  filled  ;  the  oper- 
ator places  a  pellet,  and  mallets  it  less  thoroughly  than  he  has  done  its 
predecessors.  He  adds  another,  and  continues  the  malleting.  Of 
course  the  force  of  the  blows  will  further  condense  the  under  pellet. 
Even  if  it  be  not  completely  condensed,  the  fact  that  the  shape  of  the 
remainder  of  the  cavity  is  retentive  without  regard  to  that  part  already 
filled,  makes  it  a  matter  of  no  moment  whether  that  one  pellet  is,  or  is 
not,  thoroughly  packed.  With  a  contour  filling  it  would  be  a  most 
hazardous  oversight  to  leave  even  a  single  pellet  of  gold  insufficiently 
condensed.  That  point  would  be  a  weak  spot.  However  solid  the 
rest  of  the  filling  may  be  made,  the  time  may  come  when,  under 
strong  pressure  in  mastication,  a  fracture  of  the  filling  will  occur 
just  where  that  pellet  was  placed.  If  heavy  foil  is  being  used,  the 
rule  is  even  more  imperative.  Every  layer  must  be  thoroughly  con- 
densed before  the  next  is  added,  for  the  reason  that,  with  this  kind 
of  gold  more  than  any  other,  an  underlying  layer  is  less  likely  to  be 
condensed  where  another  is  superimposed  before  the  malleting  is  com- 
pleted. For  a  similar  reason,  no  matter  how  much  need  there  may 
be  to  hurry,  the  dentist  should  never  pick  up  two  or  three  pieces  of 
heavy  foil  at  one  time  and  attempt  to  condense  them  in  that  form  ; 
the  ends,  being  irregularly  arranged,  will  fold  one  over  the  other  in 
such  shapes  as  to  offer  the  greatest  possible  resistance  to  the  mallet, 
the  result  being  improper  condensation. 

With  the  other  point,  relative  to  cohesion,  the  necessities  for  extreme 
caution,  extending  to  every  pellet,  become  evident  along  the  same 
lines  of  argument.  It  is  as  bad  for  a  filling  to  fracture  because  one 
layer  did  not  cohere,  as  because  there  was  a  flaw  from  lack  of  solidity. 
As  before,  non-cohesion,  or  slight  cohesion,  may  be  overlooked  in  the 
body  of  a  cavity  having  surrounding  walls,  because  what  is  placed 
above  it  will  still  be  retained  by  the  upper  part  of  the  cavity.  It  is 
otherwise  with  the  contour  filling.  If  only  one  layer,  especially  if  it 
be  of  heavy  foil,  fails  to  cohere,  all  that  which  follows  is  but  added 
to,'  and  is  not  a  part  of,  the  filling.  A  fracture  may  be  expected  at 
any  time. 

It  therefore  follows  that  the  size  of  the  pellets,  or  strips  of  heavy 
foil,  should  not  be  increased  near  the  end  of  the  filling  in  order  to 
hurry  the  work.  Larger  pellets  or  pieces  will  render  solidity  and 
cohesion  both  less  liable.  Above  all  things,  large  or  even  moderate- 
sized  foot-pluggers  are  to  be  avoided,  though  more  permissible  with 
the  Bonwill  mechanical  or  the  electric  mallet  than  where  a  hand-mallet 
or  hand-pressure  is  relied  upon.  I  wish  to  condemn  the  foot-plugger 
for  this  class  of  work,  yet  must  speak  with  caution.  Many  men  of  skill 
use  the  foot-plugger  with  success,  and  with  more  rapidity  than  where 


I04  METHODS  OF  FILLING   TEETH. 

another  form  was  chosen.  But  these  men  select  a  foot-plugger  which 
is  narrow,  and  reaches  a  sharp  point  at  one  end.  Thus  in  one  instru- 
ment is  had  the  action  of  a  foot-plugger,  or  of  a  point.  Such  a  plugger 
is  shown  in  Fig.  84,  and  is  most  useful.  What  I  am  advising  against  is 
a  broad,  flat,  and  unusually  long  foot-plugger.  This  con- 
_  ^'  denses  so  much  surface  at  once  that  thorough  cohesion  is 
doubtfully,  if  ever,  obtained. 

One  more  essential  point :  In  packing  any  filling  I  make 
it  my  rule  that,  from  the  very  initial  pieces,  the  shape  of  the 
cavity  must  be  such  that  I  can  use  the  mallet,  without  needing 
another  tool  to  hold  the  gold  steady.  This  is  the  rule  : 
exceptions  exist,  but  are  very  rare.  Applied  to  contour  Jill- 
ings,  the  rule  must  have  absolutely  no  exceptio7is.  Every 
piece  of  gold  as  it  is  added,  must  produce  a  filling,  as  far  as 
the  work  has  progressed,  to  dislodge  which  would  require  the  engine 
drill.  How  this  may  be  attained  in  specified  cases,  and  in  cavities 
offering  special  difficulty,  will  be  discussed  later.  I  merely  call  atten- 
tion here  to  the  fact  that,  in  contouring,  this  rule  must  hold  complete 
sway.  If  at  any  time  it  is  found  that  the  filling  will  tip,  or  move  in 
the  slightest,  the  operator  may  as  well  remove  his  gold  and  reshape 
his  cavity.  To  emphasize  this  point,  I  will  relate  a  case  which 
occurred  early  in  my  career. 

I  was  asked  by  a  dentist,  whose  experience  and 
Fig.  85.  s]^jii  were   much  respected  by  myself,  to  be  at  his 

;  j         office  one  afternoon  to  assist  him  in  placing  a  large 

contour  filling.  He  wished  me  to  mallet  and  pass 
the  gold.  I  did  so.  The  tooth  was  a  central  incisor, 
and  the  cavity  as  he  prepared  it  is  shown  in  Fig.  85. 
It  is  seen  that  the  cutting-edge  is  absent.  The  opera- 
tor had  prepared  a  cavity  retentive  in  shape,  merely 
because  with  a  wheel-bur  he  had  made  an  undercut,  or 
groove,  all  around.  This  is  exactly  the  plan  to  be  followed  in  similar 
cases,  where  from  abrasion  the  ends  of  teeth  have  been  worn  away,  and 
it  is  desired  to  stop  the  destruction  by  offering  masticating  surfaces  of 
gold.  Then  the  filling  is  n\^.A&  flush  with  the  top  of  the  tooth,  and  will 
remain  in  place  even  though  it  must  be  held  with  another  instrument  all 
through  the  process  of  packing.  (This,  of  course,  need  not  be  if  the 
groove  be  properly  shaped  to  retain  the  first  pellet.)  To  so  arrange  a 
cavity,  however, where,  as  in  the  case  which  I  am  citing,  about  one- 
quarter  of  the  length  of  the  tooth  was  to  be  restored,  was  absurd.  Thus  I 
thought,  but  of  course  made  no  comment.  The  dentist  began  with  a 
rather  large  pellet,  and  proceeded  much  as  though  he  had  been  using 
?e(?«-cohesive  gold.  That  is,  he  was  mainly  depending  upon  wedging 
the  pieces  across  from  one  groove  to  the  other,  using  one  instru- 


AMALGAM  IN  CONTOUR   WORK.  105 

ment  for  condensing  under  the  force  of  the  mallet  wielded  by  myself, 
and  another  to  prevent  the  gold  from  rocking  or  moving.  This  was 
kept  up  till  the  whole  cavity  was  filled  flush,  when  of  course  it 
appeared  solid.  Then  the  work  progressed  rapidly,  till  the  whole 
contour  was  completed,  at  the  end  of  two  hours'  work.  In  finishing 
this  filling  with  a  file,  the  dentist  succeeded  in  straining  it  fironi  its 
anchorage  so  that  it  conld  be  slightly  rocked.  He  looked  at  me  silently, 
and  I  refrained  from  speaking.  He  tipped  it  out,  and,  strange  to  say, 
proceeded  to  refill  the  cavity  without  change  of  plan.  This  time  he 
succeeded  in  making  the  contour,  and  also  in  polishing  it  so  that  it 
looked  really  handsome.  Moreover,  it  lasted  as  long  as  the  lady  lived, 
though  I  should  record  that  she  died  two  weeks  later. 

The  essential  features  of  a  gold  contour,  therefore,  are  extreme 
solidity,  extreme  cohesion,  and  extreme  immobility  throughout  and 
at  every  stage  of  the  operation. 

Amalgam. — It  is  frequently  admitted  that  amalgam  has  been  a 
much-abused  material.  This  charge  against  dentists  is  more  true  in 
relation  to  contour  fillings  than  in  any  other  connection.  It  will  not 
sufiice  to  say  that,  for  contouring,  amalgam  is  a  valuable  agent.  It 
is  necessary  to  say  that  it  is  invaluable.  Its  usefulness  is  inestimable. 
It  may  be  made  to  save  teeth  which  without  it  would  be  lost,  or,  at 
least,  even  if  saved,  would  be  of  but  slight  service  for  mastication. 

In  the  realm  of  contour  work,  amalgam  occupies  a  place  that  is 
unique.  With  it  can  be  restored  all  those  forlorn  cases,  those  wrecks, 
which  half  a  century  ago  were  inevitably  consigned  to  the  forceps. 
Yet,  with  shame  it  must  be  admitted  that  only  a  very  few  men  know 
how  to  obtain  the  most  desirable  results  with  amalgam  in  these  very 
cases.  The  man  who  can  restore  a  molar  where  caries  has  ad- 
vanced beneath  the  gum,  two  or  three  cusps  being  entirely  absent, 
and  build  upon  this  unpromising  foundation  a  tooth  which  becomes  as 
useful  as  the  original,  and  which,  moreover,  remains  permanently  in 
place  without  fretting  the  gum  and  without  inviting  decay  along  its 
borders,  has  more  right  to  count  himself  skilled  than  the  best  gold- 
filler  that  we  have  known. 

In  small  cavities  the  plastic  is  the  more  manageable  material,  but 
as  the  size  of  a  cavity  increases,  manipulation  with  gold  becomes  less 
difficult,  the  added  obstacle  being  only  the  tediousness  of  a  lengthy 
sitting.  With  amalgam  it  is  otherwise,  for  the  larger  the  cavity  the 
viore  difficult  it  becomes  to  attain  the  highest  success. 

Amalgam,  then,  in  contour  work  may  well  attract  our  special  atten- 
tion. I  must  point  out  the  obstacles  to  its  proper  use,  'and  tell  how  to 
combat  them.  How  often  have  we  all  expended  a  half-hour  or  more 
restoring  a  lost  corner  of  a  molar,  only  to  have  it  return  on  the  follow- 
ing day,  with  a  portion  of  it  missing?     We  say  to  the  patient,  "You 


I06  METHODS  OF  FILLING   TEETH. 

must  have  bitten  something  on  that  before  it  was  thoroughly  hardened, '  *' 
but  that  is  no  satisfaction  either  to  patient  or  dentist.  The  work 
remains  to  be  done  over,  and  discussion  does  not  mend  matters,  es- 
pecially as  the  same  risk  must  be  taken  again. 

This  tendency  to  fracture,  in  an  amalgam  filling,  is  due  to  several 
things.  Of  course,  if  the  occlusion  be  sharp,  the  explanation  given 
by  the  dentist  may  be  true  ;  mastication  may  have  dislodged  a  portion 
of  the  mass.  But  where  such  an  accident  is  possible,  the  dentist  must 
note  the  fact  and  guard  against  it  in  advance.  The  filling  must  leave 
him  so  shaped  that  it  will  not  be  disturbed  by  the  closing  of  the  jaws, 
even  so  much  as  by  the  production  of  a  slight  scratch.  Moreover, 
this  immunity  must  be  determined,  not  alone  by  the  perpendicular 
action  of  the  jaw,  but  by  the  lateral  as  well.  The  patient  must  be 
asked  to  gently  move  the  jaw  from  side  to  side,  as  he  would  do  in  eating. 
This  brings  the  cusps  of  the  opposing  tooth,  or  teeth,  into  all  the  differ- 
ent relations  which  they  are  to  bear,  and  if  the  filling  is  unmarred  by 
this,  the  single  warning  to  chew  upon  the  opposite  side  during  the  suc- 
ceeding day,  if  obeyed,  will  bring  the  filling  back  in  good  condition. 

But  it  is  often  by  a  cause  other  than  mastication  that  the  filling  is 
broken.  We  take  the  utmost  care  to  keep  a  gold  filling  free  from 
moisture,  yet  some  men  do  not  hesitate  to  insert  amalgam  with  the 
cavity  and  surrounding  parts  flooded  with  saliva.  This  so-called 
submarine  work  not  only  should  not  be  practiced,  but  a  clinician 
showing  It  before  assembled  students,  or  practitioners,  should  be 
roundly  condemned.  In  contour  work  with  amalgam  it  is  of  the 
utmost  importance  that  the  perfect  crystallization  of  the  mass  should 
not  be  interfered  with  by  moisture.  The  filling  should  be  kept  dry 
throughout  the  whole  operation,  if  possible.  Where  the  cavity  extends 
far  beneath  the  gum-margin,  the  tooth  may  be  filled  in  two  operations, 
though  at  the  same  sitting.  Using  the  napkin  as  a  dam,  amalgam 
must  be  packed  until  it  extends  beyond  the  margin,  sufficiently  far  so 
that  the  rubber-dam  may  be  placed.  Then  the  cavity,  and  the  amal- 
gam already  in  place,  may  be  dried  and  the  filling  continued.  Thus 
it  is  shown  that  because  a  cavity  cannot  be  kept  dry  with  rubber- 
dam  from  the  outset,  that  is  no  reason  why  the  filUng  should  be 
allowed  to  become  inundated  several  times,  through  a  vain  effort  to 
control  moisture  with  a  napkin. 

The  next  important  point  is  to  avoid  fracturing  the  mass  during  the 
operation.  This  involves  simply  the  proper  application  of  force,  and 
the  proper  consistency  of  the  material.  Amalgam,  for  use  in  a  large 
contour,  must  be  prepared  slightly  more  plastic  than  for  ordinary  work. 
It  is  to  be  packed  with  balls  of  bibulous  paper,  with  a  wiping  motion, 
thus  forcing  the  material  against  the  cavity- walls,  as  long  as  this  action 
can  be  carried  out.     By  this  course  the  excess  of  mercury  Is  forced  out» 


OXYPHOSPHATE  OF  ZINC  IN  CONTOUR    WORK.         lo; 

and  crystallization  begins  at  once.  Thenceforth  the  particles  of  that 
portion  of  the  mass  already  in  position  must  not  be  disturbed.  If  by  ex- 
erting force  in  a  wrong  direction  a  part  of  the  filling  is  fractured  off,  ii 
is  folly  to  hope  to  get  a  good  result  by  patting  it  back  with  a  burnisher. 
The  reicnion  will  not  be  as  strong  as  was  the  original  union.  It  would 
be  better,  where  the  accident  does  occur,  to  remove  the  separated 
piece,  replacing  it  with  freshly-mixed  material.  To  give  accurate 
direction  on  this  point  I  must  resort  to  a  diagram.  Fig.  86  shows  a 
large  contour  partly  completed.  The  dotted  line  shows  the  extent 
to  which  it  is  to  be  carried. 

Whether  the  remainder  of  the  filling  be  packed  with  bibulous  paper 
or  with  burnisher,  it  is  from  this  point  on  that 
fracture  is  to  be  feared.  •  The  rule   is  very  Fig.  86. 

simple. .  Pressure  vnist  be  exerted  o?ily  in  line 
with  the  greatest  resistance,  offered  by  the  tooth 
itself.  To  pack  the  amalgam  in  the  direction 
indicated  by  the  arrow  a  would  be  safe, 
whereas  to  follow  the  direction  shown  by  the 
arrow  b  would  be  to  invite  failure. 

The  last  essential  is  to  dismiss  the  filling  as 
far  advanced  toward  crystallization  as  possible.     This  may  be  best  ac- 
complished by  burnishing  gold  into  it,  as  has  been  previously  described 
on  page  64. 

Oxyphosphate  of  Zinc. — This  is  a  material  rarely  depended  upon 
for  extensive  contour  work.  Yet  there  are  two  special  conditions  in 
which  it  may  be  made  extremely  useful.  I  once  was  applied  to  by  an 
actress  who  had  lost  the  corner  of  a  central  incisor.  The  tooth  was 
unusually  large,  and  the  missing  portion  extensive.  A  gold  corner 
would  have  been  very  noticeable  to  her  audiences,  and  would  not  be 
tolerated  by  herself.  It  is  possible  that  at  some  time  in  the  future 
porcelain  fillings  will  have  been  brought  to  such  a  stage  of  perfection 
that  a  case  of  this  kind  can  be  readily  handled.  The  lady,  however, 
came  to  me  long  before  such  work  was  even  advocated.  She  simply 
asked  me  to  restore  the  tooth  with  what  she  termed  "bone-filling," 
and  I  did  so,  using  considerable  care  to  obtain  as  perfect  match  to 
color  as  possible,  and  succeeding  fairly  well.  I  replaced  this  in  less 
than  a  yean  It  must  be  remembered  that  as  soon  as  a  small  part  of 
the  mass  had  disintegrated  the  contour  was  obliterated,  so  that  re- 
filling in  this  position  would  be  needed  more  frequently  than  ordinarily. 
The  third  time  that  I  was  asked  to  fill  this  tooth,  I  observed  that  the 
wasting  away  was  mainly  from  the  palatal  side,  outward.  This  com- 
pelled me  to  think  a  little,  and  I  devised  a  mode  of  procedure  which 
1  have  since  followed  in  similar  conditions,  with  most  gratifying  re- 
sults.    I  first  restored  the  shape  of  the  tooth  as  before,    using  an 


io8 


METHODS  OF  FILLING   TEETH. 


oxyphosphate.  This  done,  I  burnished  a  thin  piece  of  tin  over  the 
palatal  portion  of  the  filling,  extending  it  partly  around  the  approximal 
surface,  and  over  the  cutting-edge,  trimming  it  to  shape.  With  this 
as  a  pattern,  I  cut  out  a  similar  piece  from  thin  gold(24-k.)  plate,  and 
treated  it  in  the  same  way,  thus  fashioning  a  tray  which  would  hold  the 
material,  and  protect  it  wherever  it  was  covered.  This  bit  of  gold 
was  then  soldered  where  the  two  turned  edges  came  together  at  the 
angle  of  the  corner,  and  a  thin  layer  of  solder  flowed  along  the  inner 
side.  Into  it  were  then  dropped  stray  bits  of  gold,  or  platinum,  and 
when  heated  up  once  more  these  were  caught  and  held  by  the  solder, 
producing  a  roughened  inner  surface.  The  filling  was  then  removed 
entirely  from  the  tooth.  Its  first  insertion  was  intended  only  to  serve 
for  molding  the  gold  tray.  The  gold  tray  was  then  held  in  place 
against  the  corner  of  the  tooth,  and  fresh  oxyphosphate  inserted. 
When  this  was  hardened  the  whole  was  finished  with  sand-paper  disks, 
and  presented  the  appearance,  from  the  palatal  aspect,  of  any  ordi- 


FiG.  87. 


Fig.  88. 


Fig.  89. 


Fig.  90. 


nary  gold  filling,  while  labially  I  had  the  oxyphosphate  simulating 
the  tooth  in  color.  In  Fig.  87  is  shown  a  tooth  prepared  for  fiUing, 
the  gold  tray  in  position  to  receive  the  phosphate.  Fig.  88  shows  the 
tray  itself,  and  the  inner  surface  here  represented  with  loops.  One  or 
two  pins  from  old  porcelain  teeth,  soldered  into  the  tray,  serve  as  well 
as  any  other  means  of  obtaining  a  point  for  the  phosphate  to  adhere 
against. 

Another  condition  where  extensive  contours  may  be  safely  effected 
mainly  with  oxyphosphate,  is  where  a  large  portion  of  a  tooth  being 
missing,  let  us  suppose  that  we  find  the  tooth  itself  intensely  sensitive, 
so  that  we  should  hesitate  to  insert  a  metallic  filling.  Or  the  patient 
may  be  of  such  temperament  that  it  would  be  hazardous  or  injudicious 
to  compel  as  long  a  sitting  as  would  be  necessary  for  the  insertion  of 
gold.  It  may  be  desirable  to  reject  amalgam,  because  the  location  is 
such  that  it  would  show,  as  for  example  the  anterior  approximal  sur- 
face of  a  superior  first  molar,  or  one  of  the  bicuspids.  The  plan  that 
I  have  followed  with  success  is  to  temporarily  restore  the  shape  of  the 
tooth  by  inserting  an  oxyphosphate  filling.  Next  I  take  an  impression 
and  dismiss  the  patient.     During  his  absence  I  mold  pure  gold  plate 


THE  USE  OF  SCREWS. 


109 


over  the  plaster  model,  forming  a  contoured  cap  to  cover  the  oxy- 
phosphate,  which  I  insert  at  the  next  sitting.  The  inner  side  of  this 
cap  is  treated  as  before,  either  with  pins  or  loops  soldered  in.     Fig. 

89  shows  a  molar  thus  filled,  the  appearance  being  simply  that  of  a 
gold  contour  filling,  because  the  edges  are  polished  down  to  the  finest 
taper,  which  can  be  done  so  nicely  that  the  point  of  an  explorer  will 
pass  over  them,  and  silk  not  catch  under  the  gingival  margin.     Fig. 

90  shows  the  cap  with  loops  within. 

It  may  be  as  well  mentioned  here  as  elsewhere,  though  not  strictly 
speaking  in  the  nature  of  contour  work, — though  all  restoration  may 
be  so  counted, — that  these  caps  for  oxyphosphate  become  invaluable  in 
the  treatment  of  children  s  permanent  teeth.  When  the  little  ones  come 
to  us  with  gaping  cavities  in  their  sixth-year  molars,  what  are  we  to  do  ? 
We  frequently  find  extensive  caries  without  real  exposure  of  the  pulp. 
It  is  greatly  desirable  to  save  these  teeth  alive,  as  a  dead  pulp  in  a 
sixth-year  molar,  at  this  time,  even  though  thoroughly  removed,  may 
almost  surely  be  counted  a  forerunner  of  an  abscess  later  in  life,  and 

Fig.  91.  Fig.  92. 


probable  loss  of  the  tooth  before  the  age  of  twenty-five.  So  far  from 
considering  these  teeth  good  subjects  for  extraction,  I  take  unusual 
pains  to  save  them.  I  think  this  can  be  accomplished  with  oxyphos- 
phate better  than  with  anything  else.  Here  again  I  fill  the  cavity 
temporarily,  in  this  condition  placing  cotton,  which  carries  a  medica- 
ment first,  and  covering  with  gutta-percha  or  temporary  stopping, 
carving  the  same  into  fair  shape  for  mastication.  I  then  take  an  im- 
pression, and  if  it  be  necessary  make  dies  and  swage  a  piece  of  pure 
gold  to  cap  my  cavity  and  give  me  a  good  masticating  surface.  Fig. 
91  shows  a  tooth  so  filled,  and  Fig.  92  the  cap  with  loop.  These  caps 
should  never  be  made  to  do  service  over  ^zdta-percha,  as  that  material 
by  swelling  may  dislodge  the  gold  covering.  In  all  cases  the  edges 
should  be  as  thoroughly  polished  down  as  though  it  were  a  true  gold 
filling. 

The  Use  of  Screws. — The  judicious  use  of  screws  in  connection  with 
the  restoration  of  teeth  which  have  been  badly  decayed,-  enables  us  to 
save  permanently  many  teeth  which  would  otherwise  be  lost — or 
crowned.  The  screw  first  comes  into  play  when  caries  has  advanced 
so  far  that  any  preparation  of  the  cavity,  removing  tooth-substance, 


no 


METHODS  OF  FILLING   TEETH. 


in  order  to  obtain  retentive  shape,  would  leave  the  remaining  portion 
so  weakened  that  fracture  subsequent  to  or  during  the  filling  opera- 
tion would  be  rendered  probable.  Again  we  resort  to  the  screw  when 
necessary  excavation  might  too  nearly  approach,  or  even  expose  the 
pulp  itself.  A  case  which  combines  both  of  these  possibilities  is  shown 
in  Fig.  93,  which  is  a  lateral  incisor  from  which  both  corners  have  been 
removed  by  carious  action.  Supposing  that  the  pulp  were  alive  in 
such  a  case,  I  think  it  better  to  restore  by  gold  contours  than  to  crown, 
even  where  crowning  could  be  accomplished  without  destruction  of 
the  pulp,  ysing  the  How  drills,  taps,  and  gold  screws,  a  threaded 
hole  is  drilled  in  the  tooth,  care  being  taken  neither  to  enter  the  pulp- 
chamber,  nor  to  pass  through  the  side.  The  screw  is  then  turned 
into  place  tightly  and  cut  off  long  enough  to  reach  almost  to  the  end 
of  the  corner  which  is  to  be  builded  on.  The  figure  shows  the  screws 
in  position.     To  secure  permanent  results,  the  greatest  skill  and  care 


Fig.  93. 


Fig.  94. 


Fig.  95. 


are  requisite  in  filling  around  the  screw.  Only  very  small  pieces 
should  be  used,  and  each  of  these  should  be  thoroughly  condensed. 
As  a  screw  renders  an  operation  doubly  difficult,  it  should  be  re- 
sorted to  only  in  cases  of  absolute  necessity.  Fig.  94  shows  a  good 
arrangement  of  screws  in  a  molar,  the  pulp  being  alive,  and  the  tooth 
so  sensitive  that  proper  excavation  of  the  cavity  becomes  of  doubtful 
expediency.  Here  we  have  four  screws  so  placed  that  they  assist  one 
another.  Where  it  is  designed  to  depend  upon  amalgam,  a  screw  of 
platinum  and  iridium  is  preferable  to  one  of  gold,  which  could  be 
readily  destroyed  by  amalgamation.  We  sometimes  find  molars  badly 
scooped  out  by  abrasion,  a  considerable  surface  of  the  dentine  being 
thus  denuded.  Occasionally  these  places  are  extremely  sensitive. 
Here  screws  may  be  depended  upon  to  do  good  service.  I  have 
placed  as  many  as  six  in  a  single  tooth,  as  shown  in  Fig.  95,  which 
represents  a  molar  ready  to  receive  the  amalgam,  no  undercutting 
having  been  attempted,  reliance  being  placed  entirely  upon  the  screws. 

In  concluding  this  subject,  I  will  give  a  few  odd  cases  from  practice 
which  may  indicate  the  unusual  application  of  principles  which  become 
necessary  in  unique  cases. 

Case  I .  A  young  lady  visiting  the  city  called  upon  me  with  the 
statement  that  she  had  fallen  and  broken  a  lateral  incisor.     Her  den- 


THE  USE  OF  SCREWS.  1 1 1 

tist,  in  the  city  where  she  resided,  did  not  care  to  undertake  the  opera- 
tion, and  as  she  was  about  to  visit  New  York  kindly  gave  her  my 
address.  Examination  showed  that  the  tooth,  if  a  lateral  incisor  at 
all,  was  misshapen,  being  indeed  a  supernumerary  tooth.  Though 
narrow,  its  loss  would  have  been  deplorable,  because  the  arch  was 
well  curved  and  filled  with  teeth  regularly  placed.  The  fi-acture  had 
removed  about  one-quarter  of  the  crown,  yet  the  pulp  had  not  become 
exposed  thereby.  The  end  of  the  tooth  was  broken  off  square,  and 
being  small  in  proportion  tothelengthofthe  restoration  required,  made 
the  chances  of  success  next  to  impossible  if  any  attempt  were  made  to 
form  a  cavity  by  undercutting,  which  should  retain  the  filling  without 
danger  to  the  pulp.  I  built  down  a  full  contour,  retaining  it  entirely 
by  three  screws.  The  arrangement  before  filling  is  shown  in  Fig.  g6, 
and  the  restored  end  in  Fig.  97.  To  start  the  filling,  I  took  a  narrow 
rope  of  gold  and  wove  it  between  and  around  the  screws. 

Fig.  96.      Fig.  97.  Fig.  98.  Fig.  99. 


Case  2.  This  case  exemplifies  another  use  of  a  screw.  The  patient 
was  a  young  man,  and  the  tooth  a  first  bicuspid.  Approximal  cavities 
liad  approached  each  other  till  the  cavity  extended  through  from 
front  to  back,  as  seen  in  Fig.  98,  which  also  shows  the  disposition 
which  I  made  of  a  screw.  The  labial  and  palatal  walls  were  so  weak 
that  they  could  be  sprung  together  slightly  between  the  fingers,  so 
that  I  feared  fracture  from  the  force  of  mastication.  As  an  additional 
precaution,  the  edges  of  the  natural  cusps  were  slightly  beveled,  so 
that  after  filling  they  were  capped  and  protected  by  the  gold,  as  shown 
in  Fig.  99.  The  ends  of  the  screw  were  ground  off  after  filling,  ap- 
pearing like  small  fillings. 

Case  3.  A  young  woman  of  twenty,  of  comely  features,  applied  to 
me  to  have  a  gold  crown  placed  over  a  first  bicuspid.  Examination 
showed  very  extensive  decay  along  the  posterior  approximal  por- 
tion, which  also  extended  so  far  up  under  the  gum-margin  that  not 
only  would  it  have  been  difficult,  but  I  thought  that  it  would  even 
have  been  impossible  to  successfully  crown  the  root  after  cutting  off 
what  was  left  of  the  natural  crown.  The  condition  is  shown  in  Fig.  1 00, 
where  it  is  seen  that  the  cavity  involves  the  root  as  well  as  the  crown. 
The  natural  crown  itself  offers  poor  support  for  a  filling,  yet  this  tooth 
was  successfully  contoured,  and  is  doing  good  service  now,  seven  years 


112 


METHODS  OF  FILLING  TEETH. 


Fig.  ioo. 


Fig.  ioi. 


Fig.  I02. 


later.  It  is  manifest  that  the  rubber-dam  could  not  be  forced  above 
the  gingival  margin.  The  procedure  therefore  was  to  secure  a 
stout  platinum  and  iridium  screw  into  the  root-canal,  the  pulp  having 

been  removed  before  I  saw  the  case. 
Around  this,  amalgam  was  packed 
until   it   protruded   sufficiently  tO' 
allow  the  dam  to   be  placed.     At 
the  next  sitting  the   contour  was 
completed  with  gold,  the  dam  being 
placed  first,  and  then  all  the  amal- 
gam cut  away  except  just  sufficient 
to  allow  the  dam  to  remain  in  posi- 
tion.    Fig.  IOI  is  a  section  showings 
the  relation  between  screw,  amal- 
gam, and  gold. 
Case  4.  A  young  man  came  to  me  on  one  occasion  with   a   first 
superior  molar  from  which  the  crown  was  lost  except  the  buccal  wall, 
yet  the  pulp  was  alive.     A  good,  serviceable  restoration  was  made 
without  cutting  away  the  tooth  to  any  material  extent.     Along  the 
palatal  margin  two  iridiumized  platinum  screws  were 
placed,  and  through  the   buccal  wall  itself  two  holes 
were  drilled.     This  wall  was  strong,  and  yet  of  such 
form  that  it  was  safer  to  resort  to  this  method  than  it 
would  have  been  to  make  an  attempt  to  undercut  it  for 
retaining  grooves.    Fig.  102  shows  the  tooth  as  prepared 
for  filling.    These  holes  were  beveled  at  the  buccal  side 
so   that  when  the   amalgam  was  placed    it    extended 
through,  forming  headed  pins,  which  materially  added  to  the  strength 
of  the  operation. 

Case  5.  A  married  woman  of  forty  came  to  me  for  a  lower  set 
of  teeth.  She  still  had  the  six  anterior  teeth  below,  but  they  were  in 
such  a  state  of  dilapidation  that  she  wished  them  extracted.  Exami- 
nation showed  that  though  badly  decayed  along  anterior  and  posterior 
approximal  sides,  in  every  instance  the  pulp  was  alive.  For  this  rea- 
son, and  because  I  considered  that  a  partial  lower  plate  would  give 
better  service  than  a  full  denture,  I  advised  saving  the  natural  teeth. 
In  every  case,  I  found  the  teeth  so  narrow  and  the  cavities  so  exten- 
sive that  I  despaired  of  being  able  to  build  on  the  necessary  corners, 
with  any  hope  of  having  them  endure.  Finally  I  resorted  to  a  plan 
which  proved  successful.  One  case  will  serve  for  illustration.  Fig. 
103  shows  a  lower  incisor  after  the  removal  of  decay.  It  is  seen  to  be 
similar  to  the  superior  lateral  incisor  shown  in  Fig.  93,  where  screws 
were  resorted  to.  This  could  not  be  done  in  the  lower  because  of  the 
danger  of  entering  the  pulp-chamber.     What  I  did  was  to  connect 


THE  USE  OF  SCREWS. 


113 


the  cavities  above  and  below,  cutting  a  groove  across  the  incisive 
^^go^,  and  another  near  the  gum  at  the  labial  aspect.  The  ca\'ity  pre- 
pared for  filling  is  shown  in  Fig.  104,  and  the  full  contour  in  Fig. 
105. 

Case  6.  A  young  girl  of  about  fourteen  presented  with  a  lower 
sixth-year  molar,  from  which  all  of  the  crown  was  absent,  the  pulps, 
however,  being  still  alive.  These  cases  are  by  no  means  uncommon. 
Of  course,  where  the  patients  can  afford  it,  they  may  be  crowned  with 
gold,  but  even  then  it  is  doubtful  whether  such  an  operation  would 
be  as  serviceable  as  the  one  which  I  am  about  to  describe,  for  two 
reasons  :  First,  the  fact  that  by  the  method  of  filling  the  davi  is  in 
positio7i  whe7i  the  cevient  is  used ;  and,  secondly,  a  better  occlusion 


Fig.  103.       Fig.  104.      Fig.  105. 


Fig.  106. 


Fig.  107. 


Fig.  109. 


can  be  obtained  where  the  ' '  bite ' '  is  short.  I  made  a  band  of  gold  to 
fit  around  the  tooth,  wide  enough  so  that  when  in  place  it  prevented 
closure  of  the  jaws.  It  was  then  removed,  and  the  upper  edge  turned 
inward  slightly  all  around.  Replaced  about  the  tooth,  closure  of  the 
jaws  pressed  the  bent  edges  down  until  the  occlusion  was  perfect.  The 
tooth  with  band  thus  turned  in  to  adapt  itself  to  the  occlusion  is 
shown  in  Fig.  106.  The  dam  was  next  adjusted,  and  cement  placed 
along  the  inner  side  of  the  band  and  covering  the  floor  of  the  cavity 
thus  formed.  Before  this  was  allowed  to 
set,  amalgam  was  used  to  complete  the  con- 
tour. This  cement  not.  only  served  to  se- 
cure the  superstructure  to  the  root,  but  it 
protected  the  gold  band  from  the  action 
of  the  mercury  in  the  amalgam.  When 
trimmed  up  and  polished,  a  handsome  and 
serviceable  crown  resulted,  as  shown  in  Fig. 
107. 

Case  7.    A  young  woman  presented  with 
a  first  bicuspid  from  which  the  entire  labial 
portion  had  been  lost.    The  tooth  was  pulp- 
less.     I  ground  a  porcelain  cuspid  to  fit  fairly  well  into  the  place  of  the 
missing  labial  wall,  and  to  this,  when  backed,  soldered  a  stout  platinum 
bar,  which  extended  down  into  the  root.     This  was  set  with  oxyphos- 


114  METHODS  OF  FILLING   TEETH. 

phate  and  the  patient  dismissed.  At  the  next  sitting  the  dam  was 
placed,  and  the  phosphate  removed  sufficiently  to  allow  a  thorough 
filling  of  gold.  Next  a  groove  was  cut  between  the  porcelain  face  and 
the  tooth  where  they  came  into  contact  at  the  labial  gum-margin, 
and  this  joint  was  made  perfect  by  gold  filling.  Fig.  io8  shows  a 
section  representing  the  relation  between  porcelain  face,  pin,  phos- 
phate, and  gold,  and  Fig.  109  shows  the  appearance  from  the  labial 
aspect,  the  porcelain  face,  and  the  gold  at  the  joint  being  seen. 


CHAPTER    V. 

Special  Principles  involved  in  the  Preparation  of  Cavities,  and 
IN  THE  Insertion  of  Fillings — Consideration  of  Approximal  Cavi- 
ties IN  Incisors — In  Cuspids— In  Bicuspids— In  Molars. 

In  the  earlier  portion  of  this  work  I  'have  given  what  I  termed 
' '  general  principles' '  in  relation  to  the  preparation  of  cavities  and  the 
filling  thereof.  I  now  purpose  to  take  up  specifically  a  sufficient  num- 
ber of  typical  conditions,  so  that  with  the  description  of  methods  neces- 
sary, the  student  may  have  the  theoretical  knowledge  which  will  enable 
him  intelligently  to  undertake  whatever  may  come  into  his  hands. 

In  the  first  chapter  I  classified  cavities  as  being  of  three  kinds,  viz  : 
approximal,  crown,  and  surface,  the  latter  including  palatal,  lingual, 
labial,  buccal,  and  festoon  cavities.  Of  these  terms,  all  serve  well 
enough,  with  the  possible  exception  of  the  word  "crown."  Strictly 
speaking  a  tooth  is  divided  into  crown,  neck,  and  root,  so  that  miy  cavity 
might  be  considered  a  ' '  crown  cavity' '  provided  it  did  not  reach  or  pass 
the  neck.  But  this  use  of  the  word  is  arbitrary,  for  the  common  mean- 
ing of  "crown"  is  "the  topmost  part,"  "the  summit."  Thus  the 
' '  crown  of  the  head' '  is  the  extreme  upper  surface.  This  latter  appli- 
cation of  the  term  has  been  made  by  many  when  speaking  of  cavities  in 
the  masticating  surfaces  of  molars  and  bicuspids.  In  the  absence  of 
a  universally  adopted  term  applicable  to  this  position,  the  words 
' '  crown  cavity' '  in  this  work  must  be  interpreted  to  mean  a  cavity  in 
the  masticating  surface  of  a  bicuspid  or  a  molar. 

Approximal  Cavities. — Of  all  cavities,  those  in  the  approximal  sur- 
faces usually  demand  the  greatest  skill  and  care.  Situated  most  often 
in  a  position  inaccessible  because  of  the  contiguity  of  the  adjacent 
tooth,  a  spreading,  or  separation  of  the  teeth,  becomes  necessary.  Even 
after  this  is  done,  it  not  infrequently  occurs  that  what  would  be  an 
easy  filling  with  ready  access,  becomes  exceedingly  difficult  because 
of  lack  of  space  in  which  to  work.     Add  to  this  the  tenderness  caused 


APPRO XIMAL   CA  VITIES  IN  INCISORS. 


115 


by  a7iy  system  of  wedging,  and  approximal  cavities  become,  of  all, 
the  most  to  be  dreaded  by  patient  and  operator.  They  usually  have 
their  initiation  at  the  point  of  contact.  Two  teeth  touch  each  other  at 
a  limited  area,  and  caries  begins  at  that  spot.  After  spreading  the 
teeth,  and  removing  stains,  there  is  seen  at  this  point  of  contact  a 
whitish,  or  chalky,  appearance  to  the  enamel.  Except  in  its  most 
incipient  form,  it  is  futile  to  attempt  to  remove  this  by  filing  or  by 
polishing.  The  caries  usually  penetrates  very  deep  in  proportion 
to  its  circumferential  area,  and  the  dentine  is  swiftly  reached.  To 
eradicate  the  caries  with  the  file  or  disk  would  be  to  expose  the  den- 
tine, and  at  all  events  to  destroy  the  integrity  of  the  abutments  of  the 
arch  by  producing  a  space,  which  is  almost  always  mischievous.  The 
best  plan  is  to  accept  the  condition,  as  a  cavity  needing  a  gold  filling. 
I  am  speaking  of  permanent  teeth,  and  advise  gold  in  all  teeth  at  all 
ages,  where  these  minute  cavities  are  discovered. 

Fig.  no  shows  such  a  cavity  in  a  central  incisor.    It  should  be  pre- 
pared with  as  little  extension  of  the  borders  as  possible,  although  mak- 


FiG.  no. 


Fig.  III. 


Fig.  112. 


ing  it  a  point  to  remove  all  carious  material  until  strong  edges  are 
reached.  There  is  a  temptation  in  these  cases  toward  enlargement, 
because  of  the  fact  that  by  so  doing  the  work  is  rendered  more  easy. 
The  excuse,  however,  is  insufficient,  and  the  practice  reprehensible. 
Indeed,  with  me  it  has  been  my  pride  to  make  perfect  fillings  of  the 
most  minute  kinds,  and  under  the  most  trying  circumstances.  To 
retain  the  filling,  a  rose  bur  may  be  used,  dipping  slightly  toward 
the  gingiva  as  indicated  at  b  and  similarly  toward  the  incisive  edge  as 
at  a.  Here  at  once  we  find  a  difference  between  ' '  general  principles" 
and  "special  cases."  I  have  in  a  former  chapter  argued  that  no  un- 
dercutting should  be  toward  the  incisive  edge,  or  at  least  that  it  should 
not  be  extensive.  But  in  these  tiny  cavities,  where  there  is  strong 
tooth-substance  in  all  directions,  we  may  allow  ourselves  the  most 
convenient  method  and  arrange  the  retaining  points  opposite  to  each 
other  as  indicated.  Even  in  these  tiny  cavities  I  require  two  exten- 
sions of  the  cavity  for  good  retention  ;  yet  again  this  is  a  rule  with  an 


Il6  METHODS  OF  FILLING   TEETH. 

exception.  Should  the  cavity  occur  nearer  the  neck  of  the  tooth,  in 
the  bulbous  portion  of  incisors,  or  in  a  cuspid  or  bicuspid,  in  either  of 
which  there  is  considerable  tooth-substance  laterally  from  labial  to 
lingual  aspects,  and  should  there  be  very  limited  space  in  which  to  work, 
it  may  often  be  both  permissible  and  advantageous  to  form  the  cavity 
as  a  single  deep  pit.  Fig.  1 1 1  shows  such  a  condition  in  a  cuspid, 
the  dotted  line  a  showing  the  inner  extension  toward  the  palatal  aspect. 

In  filling  these  cavities  with  gold,  I  follow  strictly  the  rule  pre- 
viously advanced,  to  place  in  a  cavity  only  pellets  which  will  pass  the 
orifice  without  compression.  I  therefore  prepare  special  pellets,  tiny 
in  size,  and  use  sometimes  as  many  as  a  dozen  or  more  for  a  filling 
which  when  finished  is  no  larger  than  the  head  of  a  small  pin.  Thus 
I  am  satisfied  that  I  obtain  as  perfect  a  filling  as  when  the  cavity  is 
larger  and  therefore  easier. 

Fig.  112  shows  the  opposite  extreme,  and  we  have  the  largest  ap- 
proximal  cavity  possible  in  a  central  incisor,  without  encroaching  on 
either  the  palatal  or  labial  surface.  The  preparation  of  this  and  of  all 
cavities  between  it  and  the  one  in  Fig.  no  comes  immediately  under 
the  rule  as  already  described  in  connection  with  Figs.  2  to  8  inclusive. 
To  fill  with  gold,  the  first  pellet  should  be  placed  in  the  palato-gin- 
gival  extension  at  a,  and  should  be  fixed  so  firmly  that  the  second 
and  all  subsequent  pellets  may  be  added  without  tipping  out.'  The 
filling  should  be  first  extended  along  the  palatal  groove  in  the  direc- 
tion of  ^,  great  care  being  observed  that  this  palatal  edge  shall  be 
perfectly  covered.  Next,  gold  is  carried  toward  and  into  the  labio- 
gingival  extension  at  c,  after  which  the  completion  follows  naturally, 
the  labial  edge  being  covered  last,  and  the  last  pellet  of  gold  being- 
placed  at  d.  If  this  be  analyzed,  it  will  be  found  that  I  have  here  fol- 
lowed the  general  and  most  valuable  rule,  ' '  Fill  that  part  of  the  cavity 
first  which  is  farthest  from  you.'"  If  we  may  fill  teeth  by  rule  at  all, 
I  should  say  that  this  one  axiom  has  been  of  greater  benefit  to  me  in 
practice  than  any  other  in  the  whole  realm  of  dentistry.  Its  no  less 
important  corollary  is,  "  Where  two  approxhnal  cavities,  adjacent  to 
each  other,  are  to  be  filled,  fill  that  one  first  which  would  be  least  access- 
ible were  the  other  tooth  non-carious. ' ' 

In  Fig.  113  we  see  a  large  approximal  cavity  which  encroaches  upon 
the  labial  surface.  Under  ordinary  circumstances  this  should  give  the 
operator  little  or  no  trouble.  In  addition  to  the  space  obtained  by  the 
wedging,  the  fact  that  a  part  of  the  labial  surface  is  absent  furnishes 
an  abundance  of  space  in  which  to  work.  Yet  the  mistake  should  not 
be  made  that  the  cavity  itself  affords  sufficient  space  without  wedging. 
In  a  few  instances  this  may  be  true,  but  more  frequently  a  filling  so 
placed  when  completed,  though  it  may  look  perfect  to  the  eye  of  the 
patient,  would  not  prove  to  be  so  if  examined  by  an  expert.   The  palatal 


APPROXTMAL  CA  VITIES  IN  INCISORS.  I  I  / 

border  would  show  defects,  and  it  is  because  gold  must  be  builded 
over  this  palatal  border  that  more  space  must  be  obtained  than  is  fur- 
nished by  the  loss  of  tooth-substance.  To  arrange  such  a  cavity  so 
as  to  retain  a  filling  is  readily  accomplished,  except  where  the  pulp 
is  nearly  approached,  a  condition  which  renders  more  difficult  the 
preparation  of  any  form  of  cavity.  Deep  extensions  are  to  be  made 
at  a  and  <5,  the  labio-gingival  and  the  palato-gingival  angles  of  the 
cavity.  These,  where  it  is  possible,  should  be  deep  enough  to  hold 
the  filling  of  themselves.  A  slight  groove  should  extend  along  the 
palatal  portion  c,  but  care  should  be  observed  at  this  point.  It  should 
be  neither  too  deep  nor  too  near  the  pulp,  nor  too  near  the  edge  of  the 
cavity.  Its  object  is  not  so  much  to  add  to  the  retentive  strength  of 
the  cavity  as  to  facilitate  the  packing  of  the  gold,  when  the  points  at 
a  and  b  having  been  filled  and  connected,  we  come  to  extend  the  gold 
along  this  portion.  If  there  be  a  slight  groove  we  avoid  tipping.  At 
d,  which  is  toward  the  incisive  edge,  we  avoid  anything  in  the  nature 
of  an  undercut,  but  it  Is  wise  to  produce  a  well-marked  concavity  which 
will  serve  as  a  counterpoise  to  the  upper  retainers.  Along  the  labial 
border  e  there  should  be  no  grooving,  or  undercutting  of  any  kind. 
Such  a  procedure  only  undermines  the  enamel,  producing  a  weak 
edge  with  probable  fracture  during  the  operation,  or  at  least  the  pro- 
duction of  a  crack  which  will  later  bring  the  tooth  back  to  us  with  an 
Imperfection  at  this  point.  No  strength  whatever  Is  gained  for  the 
filling,  so  that  nothing  but  mischief  can  accrue. 

To  fill  this  cavity  with  gold,  the  first  pellet  is  to  be  placed  In  the 
palato-gingival  extension  b,  which  should  be  so  formed  that  It  will  hold 
it  without  tipping.  I  anneal  this  pellet  and  mallet  it  to  place.  It  should 
be  large  enough  to  be  readily  wedged  to  place.  The  succeeding  pellets 
should  be  small  enough  to  reach  their  predecessors  without  compres- 
sion, and  each  should  be  malleted  thoroughly.  The  correct  shaping 
of  a  retaining  point  is  rendered  futile  unless  the  filling  be  solidly  packed 
into  it.  Otherwise,  though  it  may  retain  what  is  In  it,  it  will  fail  to 
retain  the  bulk  of  the  filling  to  which  It  should  lend  strength.  From 
the  palato-gingival  extension  proceed  toward  the  labio-glnglval  pit  a, 
and  when  both  are  thoroughly  and  solidly  filled,  proceed  to  cover  the 
palatal  groove  c  and  the  cavity-edge  at  this  point.  Here  It  will  be 
wise  to  use  hand-pressure  for  a  brief  period.  With  this  milder  force 
pack  the  gold  along  the  groove  and  over  the  edge  until  a  thin  layer 
reaches  the  Incisive  concavity  at  d,  when  the  mallet  may  be  resumed. 
In  this  way  we  avoid  fracturing  the  palatal  edge  by  saving  it  from  direct 
contact  with  the  mallet-stroke.  From  this  point  On,  the  only  care 
needed  is  to  constantly  bear  in  mind  the  rule,  to  fill  the  part  farthest 
from  us  first,  being  sure  that  it  is  made  full  enough.  Otherwise  we 
find  the  filling  pitted  when  we  come  to  polish  It. 


ii8 


METHODS  OF  FILLING   TEETH. 


Fig.  114  is  the  direct  opposite  of  the  last,  and  yet  there  are  points 
of  similarity  which  some  do  not  note.  The  approximal  cavity  here 
encroaches  upon  the  palatal  surface.  Where  the  loss  of  the  labial 
surface  simplifies  the  operation,  the  absence  of  a  part  of  the  palatal 
surface  greatly  complicates  it.  There  is  a  curious  fact  to  be  observed 
here.  Whereas  many  look  upon  the  cavity  shown  in  Fig.  113  as  one 
which  easily  retains  a  filling,  some  are  much  disturbed  by  the  cavity 
in  Fig.  114.  The  first,  apparently,  is  safe,  because  a  filling  will  not 
jump  up  toward  the  labial  aspect,  whilst,  per  contra,  gravitation  may 
have  a  tendency  to  cause  a  filling  to  drop  down  and  out  at  the  palatal 
opening.  Those  who  argue  thus  are  deceived  into  this  error  of  judg- 
ment by  the  fact  that  when  the  cavity  is  seen  the  patient  is  in  the  recum- 
bent position,  which  makes  the  labial  side  of  a  tooth  up,  and  the 
palatal  side  down.  It  should  be  remembered  that  when  the  patient  is 
standing  erect  there  is  neither  up  nor  down  to  this  condition,  and 
therefore  whatever  arrangement  will  retain  a  filling  in  a  labio-approx- 


FiG.  113. 


Fig.  114. 


Fig.  115, 


imal  cavity  will  serve  equally  well  in  a  palato-approximal  one.  Conse- 
quently the  formation  of  the  two  classes  of  cavity  are  similar,  though 
not  identical.  We  have  the  same  extensions  at  a  and  b,  the  same 
groove  at  c,  the  same  concavity  at  d,  and  the  same  absence  of  under- 
cutting at  e.  But  we  find  that  c  and  e  have  changed  places  in  the  two 
illustrations.  In  the  previous  one  c  represented  the  palatal  part, 
whereas  now  it  becomes  the  labial.  A  similar  change  occurs  in  placing 
the  gold.  The  first  pellet  is  to  be  placed  in  the  labio-gingival  exten- 
sion, and,  after  the  palato-gingival  retainer  has  been  connected  with 
it,  we  then  follow  along  the  groove,  which  here  is  at  the  labial  instead 
of  the  palatal  border,  so  that  we  practically  reverse  the  order  of  pro- 
cedure. Yet  really  we  do  not,  for  now  we  are  using  a  mirror,  and  in 
the  reflection  this  labial  groove,  though  actually  nearer  to  us,  appears 
to  be  farthest  from  us,  and  in  this  instance  we  must  fill  by  appearances. 
If  the  operator  is  not  skilled  enough  to  use  the  mirror,  he  then  tips 
the  chair  back  and  lowers  his  head,  so  that  in  that  position  the  labial 
groove  becomes  really  the  farthest  point  from  his  vision. 

In  Fig.  115  we  see  a  cavity  which  is  practically  a  combination  of  the 
last  two.     We  have  presented  an  approximal  cavity  in  a  central  incisor 


APPROXIMAL  CAVITIES  IN  INCISORS.  119 

which  encroaches  upon  both  the  labial  and  the  palatal  surfaces.  Where 
these  cavities  are  extensive,  as  pictured,  they  are  usually  trying.  The 
question  has  been  raised  by  some  authorities  as  to  whether  or  not  the 
whole  corner  should  be  removed.  I  have  already  sufficiently  expressed 
my  own  views  upon  this.  If  in  either  of  the  previous  two  cases  we 
gained  anything  by  the  presence  of  the  labial  or  palatal  wall  which 
remained  intact,  what  are  we  to  do  here  in  the  absence  of  both  ?  In 
each  of  the  other  cases  I  argued  that  the  groove  which  I  advocate  is 
not  for  retention,  but  to  facilitate  filling.  Consequently,  in  the  present 
instance,  when  both  walls  are  absent,  we  may  still  feel  safe  with  pre- 
cisely the  same  arrangement, — labio-  and  palato-gingival  extensions  at 
a  and  b,  a.  slight  concavity  at  d,  and  a  groove  as  before.  The  ques- 
tion now  arises,  Shall  this  groove  be  placed  at  the  labial  or  at  the 
palatal  border  of  the  cavity  ?  The  answer  indicates  the  method  of 
proceeding  with  the  filling,  for  the  groove  is  only  intended  as  a  leading 
gutter  for  the  gold  as  we  pass  from  the  gingival  toward  the  incisive  por- 
tion. In  this  instance  we  place  the  groove  along  the  palatal  border  c, 
for  that  becomes  the  distant  portion,  and  must  be  filled  prior  to  the 
labial. 

I  have  said  that  this  arrangement  will  be  safe,  but  it  will  be  so  only 
so  long  as  the  natural  corner  remains  intact.  Elsewhere  I  have  said 
that  the  filling  must  be  so  strongly  anchored  above  that,  in  case  of 
subsequent  loss  of  the  natural  corner,  a  gold  substitute  may  be  built 
on  without  removal  of  the  original  filling.  To  accomplish  this  the 
labio-  and  palato-gingival  extensions  must  be  made  as  deep  as  possible 
with  safety,  and  must  continue  as  deep  grooves  toward  the  incisive  end, 
relatively  about  as  far  as  /  on  the  labial  aspect  and  c  at  the  palatal. 
The  upper  half  of  the  filling  is  thus  securely  held  in  three  directions, 
the  palatal,  the  gingival,  and  the  labial. 

in  filling,  after  connecting  the  upper  retainers  and  building  along  the 
palatal  border  into  the  incisive  concavity,  care  must  be  taken  to  restore 
the  lost  palatal  wall  before  attempting  to  fill  the  main  part  of  the  cav- 
ity. In  plainer  language,  manipulate  the  gold  so  that  presently  the 
cavity,  partly  filled,  will  appear  similar  to  that  in  Fig.  1 13,  where,  the 
palatal  wall  being  intact,  I  said  the  filling  becomes  simple  and  easy. 
If  another  method  be  pursued  and  the  whole  of  the  cavity  be  floored 
over  first  so  that  it  is  lined  with  gold,  we  but  add  to  our  work,  for  we 
simply  reduce  the  size  of  a  difficult  cavity  without  altering  its  shape. 
When  half  completed,  the  continuance  will  be  more  difficult  than 
the  beginning,  whereas  in  the  method  which  I  advise  we  constantly 
lessen  the  task,  making  the  cavity  simpler  and  simpler 'as  ii<e  coyitimi- 
oiisly  alter  the  shape.  But  even  by  this  method  only  the  most  skillful 
operator  can  have  a  perfect  filling  when  he  has  placed  the  last  pellet 
along  the  labial  border  <f ,  so  that  the  work  seems  ended.   Examination 


I20 


METHODS  OF  FILLING   TEETH. 


of  the  palatal  surface  of  the  filling  with  a  mirror  will  almost  invariably 
disclose  the  fact  that  the  young  operator  has  not  made  the  filling  full 
enough,  or  the  surface  solid  enough,  to  allow  for  perfect  contour  after 
polishing.  It  is  therefore  essential  for  beginners,  and  wise  for  older 
men,  to  examine  this  aspect  of  the  filling  before  removing  the  dam. 
Usually  gold  must  be  added  and  contour  filled  out.  In  fact,  it  should 
be  the  rule  to  polish  all  fillings  before  removal  of  the  dam,  except 
where  in  special  cases  a  sufficient  reason  appears  for  finishing  the  fill- 
ing at  a  subsequent  sitting. 

Next  we  must  consider  labio-approximal  and  palato-approximal 
cavities  of  another  class.  Fig.  ii6  shows  a  labio-approximal  cavity 
which  differs  from  that  seen  in  Fig.  113  in  that  the  caries  has  re- 
moved the  enamel  as  far  as  the  cutting-edge,  along  the  labial  border. 
This  is  a  rare  condition,  but  is  seen  occasionally. 

The  preparation  of  this  cavity  is  practically  similar  to  that  of  Fig. 
115.     The  filling  must  be  retained  from  above.     Here,  however,  it  is 


Fig.  116. 


Fig.  117. 


Fig.  1x8. 


Fig.  119. 


impossible  to  make  an  incisive  concavity  at  d,  because  of  the  absence 
of  the  labial  plate.  It  is  undesirable  to  form  an  undercut  at  this  point, 
and  we  should  also  abandon  the  groove  along  the  palatal  border  below 
c,  but  it  may  be  made  along  the  labial  border  e  with  some  advantage. 
Unless  the  palatal  plate  be  excessively  weak,  it  is  seen  from  the  fore- 
going that  I  should  not  remove  it.  It  will  serve  as  a  protection  to  the 
filling  during  mastication,  relieving  it  from  the  strain  that  would 
endanger  the  contour  filling  which  would  result  were  this  part  of  the 
tooth  sacrificed.  At  the  same  time  the  filling  must  protect  it  also,  as 
well  as  be  protected  by  it.  To  accomplish  this,  the  extreme  cutting- 
edge  should  be  removed,  as  shown  in  the  illustration,  so  that  the  gold 
may  be  built  over  it,  thus  protecting  it  from  the  antagonism  of  occlu- 
sion. No  special  directions  are  needed  for  the  packing  of  the  gold 
beyond  the  cautions  already  emphasized  to  pack  solidly,  using  small 
pellets,  and  heavy  foil  for  the  final  portion. 

Fig.  117  shows  a  palato-approximal  cavity  similar  to  the  last,  in 
that  the  depredation  reaches  the  cutting-edge.  This  is  one  of  the 
most  trying  cavities  that  can  be  presented,  and  one,  too,  which  occurs 
with  unpleasant  frequency.     To  remove  the  labial  plate  would  be  to 


APPRO XIMAL  CA  VITIES  IN  INCISORS.  1 2 1 

simplify  matters  vastly,  but  if  such  a  procedure  was  wrong  in  the  last 
cavity,  it  would  be  doubly  so  in  this.  In  the  former  instance  the 
retention  of  the  palatal  plate  gave  only  an  added  support  to  the  gold, 
whereas  here  the  labial  plate  not  only  serves  the  same  purpose,  but 
it  also  covers  and  hides  the  gold  from  view.  An  extensive  filling  of 
this  nature  may  be  placed  and  scarcely  be  seen  from  a  front  view. 
Wherever  there  is  found  sufficient  strength,  therefore,  to  this  part  of 
a  tooth,  I  should  allow  it  to  remain.  As  in  the  last  case,  the  cut- 
ting-edge should  be  removed,  allowing  the  gold  to  be  built  over  it, 
thus  protecting  it.  But  for  cosmetic  effects  only  the  merest  trifle 
should  be  taken  away,  so  that  barely  a  line  of  gold  will  show  from 
the  front.  The  formation  of  the  cavity  is  the  same  as  in  the  last 
instance,  save  that  the  groove  now  occurs  along  the  palatal  border, 
to  avoid  weakening  the  labial  plate. 

The  insertion  of  the  filling  will  tax  the  skill  of  beginners,  as  it  does 
that  of  many  of  mature  experience.  This  is  one  of  those  conditions 
where  a  judicious  alternation  of  mallet  and  hand-pressure  produces 
the  most  satisfactory  results.  Because  of  the  inaccessibility,  and  be- 
cause of  the  difficulty  to  see  all  parts  of  the  cavity,  the  danger  from 
fracture  by  the  mallet  blow  is  increased  tenfold.  My  habit  is  to  partly 
condense  every  piece  by  hand-pressure  before  taking  up  the  mallet. 
Of  course  this  is  slow,  but  rapidity  is  not  invariably  preferable.  The 
main  point  always  is  to  obtain  the  best  result,  in  safety.  If  the  ope- 
rator has  a  chair  which  will  allow  him  to  tip  his  patient  back,  so  that 
he  can  see  directly  into  the  cavity,  it  would  be  a  most  advantageous 
procedure.  If  not,  he  must  be  skilled  in  the  use  of  a  mirror  and  de- 
pend upon  it.  After  filling  the  labio-  and  palato-gingival  extensions, 
I  should  gradually  extend  the  gold  toward  the  cutting-edge,  following 
the  groove  and  covering  the  whole  inner  surface  with  a  veneer  of  gold. 
Up  to  this  point  I  should  use  the  mallet  but  sparingly,  but  with  this 
protection  supplied  to  the  weak  wall,  the  mallet  may  be  used  for  com- 
pleting the  filling  with  less  fear.  A  momentary  warning,  however, 
against  too  free  a  use  of  hand-pressure  !  Beware  lest  in  the  attempt 
to  conscientiously  condense  the  gold  too  much  force  be  exerted,  and 
a  fracture  occur.  More  teeth  have  been  broken  by  hand-pressure  thayi 
with  the  viallet. 

Next  we  reach  the  condition  where  the  depredation  has  removed 
the  corner.  The  restoration  of  these  teeth  is  classed  with  contour 
fillings,  but  they  are  also  approximal  cavities.  An  important  warn- 
ing is  to  be  given  at  the  very  outset.  Be  sure  to  obtain  sufficient  space 
in  which  to  work.  The  absence  of  the  corner  is  apt  to'prove  mislead- 
ing. Apparently  there  may  be  abundance  of  space,  especially  where 
the  cavity  is  extensive.  In  reality  there  never  is,  where  the  teeth  are 
normally  situated,  and  the  neighbor  has  not  been  removed.     The 


122  METHODS  OF  FILLING   TEETH. 

test  will  be  at  the  gingiva.  Here  it  will  be  seen  at  once  that  but  little 
space  exists  between  the  teeth.  Whilst  the  restoration  may  be  made 
without  separation,  the  polishing  of  the  approximal  surface  of  the 
filling  must  necessarily  produce  a  permanent  space.  This  can  be 
avoided  only  by  spreading  the  teeth,  overbuilding  the  gold,  and  pol- 
ishing so  that  when  completed  the  original  width  and  shape  of  the 
tooth  is  restored. 

In  Fig.  Ii8  we  see  a  central  incisor  from  which  the  corner  has  been 
lost.  Is  any  special  direction  needed  for  the  proper  preparation  of 
the  cavity?  In  speaking  of  the  cavities  illustrated  by  Figs.  113,  114, 
116,  and  117,  I  have  said  that  the  groove  at  the  labial  or  at  the  palatal 
border  was  less  for  retentive  purpose  than  for  facilitating  the  operation 
of  filling.  In  Fig.  115,  however,  I  advised  that  the  upper  retaining 
extensions  should  terminate  toward  the  incisive  edge  in  grooves  which, 
extend  about  half-way.  This  was  in  view  of  the  possible  future  loss 
of  the  corner.  Thus  it  is  seen  that  though  I  do  7iot  depe7id  upon  lateral 
grooves  in  the  presence  of  the  natural  corner,  in  its  absence  I  do,  more 
or  less.  Thus  in  such  a  cavity  as  shown  in  Fig.  118,  after  arranging 
the  upper  portion  as  described  in  Fig.  115,  I  should  continue  the 
grooves  toward  the  incisive  region,  lessening  them  in  depth  and  extent 
until  they  meet  about  at  d.  Some  dentists  make  a  deep  dip  inward, 
that  is  to  say  toward  the  pulp,  at  this  pointy  endeavoring  to  obtain  a. 
retaining-pit.  The  result  usually  is  that  because  of  the  narrowness  of 
the  tooth  in  this  region,  this  undercutting  leaves  the  labial  plate  of 
enamel  so  thin  that  the  gold  is  seen  through  it  when  the  filling  is  com- 
pleted. Worse  than  this,  the  enamel  often  appears  cracked,  and  I 
have  seen  not  a  few  cases  where  it  has  chipped  out  afterward.  Let. 
us  consider  for  a  moment  what  is  gained  by  an  extension  such  as  is 
indicated  by  the  dotted  Hne  e. 

The  object  of  any  undercutting  is  of  course  to  prevent  the  filling 
from  being  forced  out  of  the  cavity.  Supposing,  then,  that  a  strain 
tends  to  press  the  filling  out  laterally,  that  is  to  say  toward  the  adja- 
cent tooth,  will  this  incisive  undercut  prevent  this?  If  the  sur- 
rounding wall  be  quite  strong  it  might  have  such  a  tendency,  but  the 
real  resistance  would  be  found  in  the  palatal  and  labial  grooves,  which, 
extending  the  f till  length  of  the  filling,  thoroughly  protect  it.  The  fill- 
ing will  scarcely  be  movable  toward  the  gingival  wall,  for  there  we 
have  the  greatest  resistance  and  the  best  arrangement  for  retention. 
Can  the  filling  move  downward  toward  the  incisive  edge  ?  If  so,  this 
undercut  might  serve.  But  there  is  nothing  but  gravitation  to  urge 
such  a  movement,  and  that  is  so  slight  that  the  upper  extensions  are 
a  million  times  more  than  adequate.  Consequently  we  find  that  no- 
thing is  gained  by  the  procedure.  Is  anything  lost  ?  All  undercutting 
which  is  unnecessary  to  the  retention  .  of  a  filli?ig  is  mischievous.      In 


APPROXIMAL  CA  VITIES  IN  INCISORS. 


123 


this  instance  it  would  be  especially  so,  since  it  weakens  the  incisive 
end  of  the  tooth,  the  very  point  which  must  sustain  the  full  and  first 
strain  of  mastication. 

It  follows,  then,  that  we  may  depend  entirely  upon  the  labio-  and 
palato-gingival  extensions,  together  with  the  labial  and  palatal  groov- 
ing, to  retain  approximal  contours  such  as  shown  in  this  figure. 

When  the  depredation  becomes  so  extensive  that  the  grooves  would 
encroach  upon  the  living  pulp,  we  are  compelled  to  adopt  new  methods. 
Fig.  119  shows  a  cavity  of  this  nature.  Strictly  speaking,  the  line 
of  the  original  pulp-chamber  has  here  been  passed,  the  pulp  having 
receded  before  the  approach  of  the  decay,  a  common  occurrence. 
Sometimes  we  may  even  see  the  plain  outline  of  what  was  once  the 
chamber  now  filled  with  secondary  dentine.  To  make  the  lateral 
grooves  here  would  be  hazardous.  To  arrange  the  cavity  as  described 
in  Fig.  115,  depending  only  upon  the  upper  retainers,  might  prove 
ineffectual.  In  this  dilemma  the  screw  comes  to  our  assistance,  ar- 
ranged as  in  the  illustration.  Up  to  the  point  where  the  screw  be- 
comes a  necessity  there  is  no  imaginable  cavity  which  cannot  be  shaped 
to  retain  a  filling,  and  in  teeth  from  which  the  pulps  have  been  removed 
we  are  seldom  driven  even  to  this  extremity.  I  have  built  down  from 
the  gum  line  complete  crowns  on  centrals,  laterals,  cuspids,  and  bicus- 
pids, without  resorting  to  screw  or  post,  and  yet  have  obtained  durable 
(though  according  to  present  standards  and  in  the  presence  of  the 
porcelain  crown  unsightly)  results. 

Where  we  use  the  screw  to  retain  such  a  filling  as  would  be  needed 
in  Fig.  119,  we  still  have  the  labio-  and  palato-gingival  extensions, 
the  screw  passing  upward  along  the  median  line.  My  method  of  fill- 
ing is  to  pack  my  gold  solidly  into  my  upper  retainers  first,  connecting^ 
them.  Then  I  drill  through  the  gold  thus  placed  and  into  the  tooth- 
substance  beyond.  The  drill-hole  is  then  tapped,  the  screw  turned 
tightly  into  place,  and  cut  off  just  short  enough 
not  to  reach  to  the  line  of  the  incisive  edge,  after  ^^-  ^^°* 

which  the  filUng  is  completed  with  small  pieces,  care 
being  taken  to  properly  surround  the  screw. 

In  Fig.  120  we  have  the  extreme  condition  where 
but  one  corner  is  involved.  These  cases  are  usu- 
ally the  result  of  fracture,  though  they  sometimes 
occur  where  such  a  cavity  as  Fig.  119  has  been 
improperly  filled,  with  the  result  of  subsequent 
decay  and  destruction  along  the  incisive  edge.  As  the  latter  would  be 
the  simpler,  I  will  speak  only  of  such  as  result  from  accidental  blows. 

These  cases  are  frequently  very  puzzling.  They  most  often  occur 
during  childhood.  When  they  do,  unless  the  pulp  be  exposed,  as 
unfortunately  sometimes  occurs,  or  unless  the  pulp  should  die  as  the 


124 


METHODS  OF  FILLING   TEETH. 


result  of  the  concussion,  it  is  wiser  not  to  attempt  any  operation  at 
all  until  the  sixteenth  to  eighteenth  year.  By  that  time,  especially  if 
the  patient  be  a  female,  something  must  be  done.  Should  it  be  de- 
cided to  contour  with  gold,  the  first  step  will  be  to  determine  whether 
the  two  centrals  may  be  shortened  with  impunity.  This  often  is  a 
material  advantage.  A  case  from  practice  will  best  illustrate.  A  pa- 
tient came  to  me,  a  young  woman,  with  two  leaky  fillings  appearing 
as  seen  in  Fig.  121.  The  two  centrals  drooped  considerably  below 
the  laterals,  as  often  occurs,  and  I  shortened  them.  After  refilling 
they  appeared  as  in  Fig.  122.  To  return  to  Fig.  120  ;  should  shorten- 
ing not  be  desirable,  which  of  course  would  reduce  the  condition  to  an 
approximation  of  Fig.  119,  we  must  decide  upon  an  arrangement  of 
the  cavity  which  will  retain  this  unusually  extensive  contour.      In  the 


Fig.  121. 


Fig.  122. 


Fig.  123. 


main  this  will  be  the  same  as  in  Fig.  119,  including  the  screw,  but  in 
addition  to  this,  now  that  we  may  reach  the  opposite  side  of  the  pulp- 
canal  we  may  with  advantage  form  a  retaining  extension  in  the  direc- 
tion shown  by  the  dotted  line  at  a.  It  must  not  be  forgotten,  how- 
ever, that  there  is  danger  of  reaching  an  elongated  cornuaof  thepulp 
at  this  point,  and  the  preparation  must  be  advanced  with  great  cau- 
tion, extreme  sensitiveness  being  a  danger  signal  not  to  be  overlooked. 
Although  this  retainer  would  be  an  advantage,  it  is  not  a  necessity, 
and  should  not  be  obtained  at  the  expense  of  possible  need  for  de- 
struction of  the  pulp. 

Up  to  this  point  it  is  of  course  immaterial  whether 
the  cavities  described  occur  on  the  mesial  or  distal 
surface.  In  either  case  they  would  be  treated  alike. 
Should  they  occur  on  both  surfaces  of  a  tooth,  each 
would  be  a  condition  by  itself,  without  relation  to  the 
other.  There  comes  a  point,  however,  where  approxi- 
mal  cavities  occurring  on  both  distal  and  mesial  sur- 
faces of  the  same  tooth  do  bear  a  relation  to  one  another, 
and  materially  alter  the  rule  of  management.  Fig. 
119  has  been  introduced  to  mark  the  point  at  which  we  abandon  the  sole 
•dependence  upon  retentive  shaping  and  resort  to  the  screw.  Should 
two  such  cavities  occur  in  one  tooth  of  nearly  the  pictured  dimension, 
we  would  no  longer  need  a  screw.  Fig.  123  shows  such  a  tooth 
after  the  insertion  of  the  filling.     It  suffices  to  convey  my  idea.     It  is 


APPRO XIMAL   CAVITIES  IN  INCISORS. 


125 


seen  that  the  slight  portion  of  the  incisive  edge  which  remained 
standing  has  been  entirely  removed,  so  that  the  two  cavities  become 
thus  united.  By  this  procedure  we  have  a  single  though  extensive 
cavity  to  deal  with,  and  the  strong  retaining  powers  of  the  gingival 
portion  of  the  cavity  at  each  side  readily  retain  the  whole  mass,  oper- 
ating as  they  do  to  counterbalance  each  other.  The  cosmetic  effect 
here  is  better  than  where  an  effort  is  made  to  preserve  the  trifling 
bit  of  the  incisive  edge  of  the  natural  tooth  which  remained,  so  that 
the  arrangement  is  good  both  for  durability  and  for  appearance. 

An  analysis  of  the  directions  given  up  to  this  point  discloses  the  fact 
that  in  every  cavity  the  main  reliance  for  retention  is  upon  the  depth 
and  strength  of  the  labio-  and  palato-gingival  extensions.  The  latter 
especially  is  the  dependence.  In  making  these  extensions  we  are  of 
course  obliged  to  avoid  exposure  of  the  pulp.  Therefore  they  must  be 
made  between  that  organ  and  the  external  surfaces,  and  distant  enough 
from  each  to  avoid  disaster.  The  pulp  lies  nearer  to  the  labial  surface  at 
this  part  of  the  tooth  than  it  does  to  the  palatal,  for  the  reason  that 
on  the  palatal  surface  near  the  neck  there  is  a  considerable  bulge.  It 
is  in  this  thick  portion  of  the  tooth  that  we  can  anchor  many  fillings 
which  otherwise  would  seriously  annoy  us. 

What,  then,  are  we  to  do  with  those  cavities  which  present  with  great 
depredation  about  the  very  part  in  which  these  two  important  anchor- 
ages are  to  be  placed  ?  A  single  example,  choosing  an  extreme  case, 
will  serve  for  all.  Fig.  124  shows  a  central  incisor  in  a  condition  of 
almost  total  wreck.  Caries  has  passed  beyond  the  enamel  line  and 
encroached  upon  the  root  itself  at  the  neck.  It  has  burrowed  along 
the  labio-gingival  angle  until  seemingly  there  is  little  hope  for  anchor- 
age there.  It  has  eaten  away  a  good  share  of  the  palato-gingival 
angle,  so  that  our  mainstay  in  that  position  appar- 
ently must  be  abandoned.  In  such  an  extremity  Y\g.  124. 
we  might  hope  to  depend  upon  lateral  grooves, 
but  here  we  find  that  tooth-structure  has  been  lost 
until  we  are  almost  at  the  plane  of  the  pulp-canal 
itself.  Even  what  is  left  of  the  corner  is  weak. 
Yet  the  pulp  is  alive,  and  therefore  if  it  can  be 
filled  with  gold  the  tooth  perhaps  would  last  longer 
than  were  it  fitted  up  with  a  crown.  It  can  be 
filled,  and  well  filled,  with  gold.  How  are  we  to 
proceed  in  this  case  ?  Give  attention  first  to  the  labio-gingival  angle, 
at  a.  The  caries  passes  as  a  sort  of  horn  toward  the  labial  festoon. 
Use  first  a  rose  bur  as  wide  as  the  cavity  at  a,  and  deepen  as  far  as 
possible  without  danger  to  the  pulp.  Then  with  a  small  bur  undercut 
this  place  toward  the  gum  and  toward  the  incisive  edge.  This  forms 
what  might  be  termed  a  dovetail.     I  have  elsewhere  said  that  I  do  not 


126  METHODS  OF  FILLING    TEETH. 

connect  the  labio-gingival  and  palato-gingival  extensions  by  a  groove. 
That  is  because  ordinarily  such  undermining  would  weaken  the 
enamel  remaining  at  this  point.  Here  we  find  that  carles  has  removed 
the  enamel.  The  root  has  been  encroached  upon.  We  need  no 
longer  dread  fracture,  since  the  enamel  has  vanished,  and  we  may 
consequently  make  as  deep  a  groove  as  possible,  from  our  labial  dove- 
tail toward  the  palatal  angle  as  shown  aty.  Now  we  reach  the  palato- 
gingival  angle,  or  what  is  left  of  it.  While  we  cannot  get  the  strong 
retainer  that  we  ordinarily  obtain,  yet  the  bulbous  portion  of  the  tooth 
extends  all  along  the  palatal  aspect,  and  much  of  it  is  at  our  dis- 
posal. Continuing  downward  from  the  gingival  groove,  we  make 
a  deep  undercut  into  this  bulbous  portion  at  b,  and  obtain  an  an- 
tagonizing retainer  for  the  labial  dovetail  at  a.  Next  with  fine  burs 
cut  deep,  narrow  grooves  along  the  labial  and  palatal  borders,  pass- 
ing just  between  the  pulp  and  the  two  outer  surfaces,  at  c  and  e. 
At  d  attempt  no  more  than  the  usual  incisive  concavity.  I  have 
filled  just  such  cavities  as  this,  where  the  caries  had  gone  even 
farther  and  removed  the  natural  corner.  Consequently  I  know  that 
even  here  we  need  no  undercut  at  d.  Lastly,  with  a  small  rose  bur, 
dip  the  bur-head  here  and  there,  in  all  undercuts,  and  wherever  it 
can  be  done  with  safety.  The  object  is  to  make  the  surface  of  the 
cavity  as  rough  as  possible.  If  this  cavity  be  filled  with  quite  small 
pieces,  made  thoroughly  cohesive,  and  packed  carefully  into  every 
undercut  and  roughness,  it  will  be  found  in  place  years  afterward. 

I  believe  I  may  now  pass  from  the  central  incisor  to  other  teeth. 
Of  lateral  incisors  there  is  little  to  be  said  which  is  not  covered  by 
cases  in  the  central.  It  must  be  remembered  that  being  a  smaller 
tooth  it  is  frailer,  and  therefore  very  deep  undercuts  are  to  be  decided 
upon  with  extreme  caution.  There  is  one  very  odd  circumstance  that 
I  may  allude  to.  I  have  noted,  after  a  careful  study  of  the  facts,  that 
seemingly  the  superior  lateral  incisor  is  more  prone  to  abscess  than 
the  centrals,  or  possibly  than  any  other  teeth  at  all.  I  have  also  come 
to  the  conclusion  that  the  pulp  of  a  lateral  incisor  is  less  responsive, 
painfully,  than  any  other.  It  is  more  easy  to  destroy,  and  more  apt 
to  die  under  a  filling.  In  short,  it  seems  to  have  less  vitality.  This 
leads  one  to  be  more  cautious  in  preparing  cavities,  for  it  is  not  at  all 
uncommon  to  find  a  pulp  exposed  after  one  has  begun  to  place  his 
gold,  when  the  excessive  heat  of  a  freshly  annealed  pellet  at  last 
causing  pain  attracts  the  dentist's  closer  attention,  and  causes  him  to 
discover  a  minute  exposure,  over  which  engine-burs  and  excavators 
may  have  passed  without  remonstrance  from  the  patient.  Thus  we 
might  easily,  through  rapid  excavation,  actually  expose  a  pulp,  which 
accident  could  have  been  avoided  by  more  caution,  born  of  the 
knowledge  that  lateral  incisor  pulps  are  comparatively  irresponsive. 


APPRO XIMAL   CAVITIES  IN  CUSPIDS.  127 

In  the  cuspids  we  have  the  same  general  rules,  with  one  or  two 
notable  exceptions.  I  have  argued  against  any  undercutting  at  the 
incisive  corner  of  a  cavity,  and  also  to  some  extent  against  extensive 
grooving  along  the  labial  and  palatal  borders.  This  is  changed  in  the 
cuspid,  for  here  we  have  proportionately  more  tooth-substance  between 
the  pulp  and  the  outer  surfaces.  Fig.  125  shows  a  cuspid  having  a 
cavity  similar  to  that  in  the  central  in  Fig.  115.  What  was  a  quite 
difficult  condition  in  the  central  is  much  more  simple  in  the  cuspid, 
so  far  as  preparation  of  the  cavity  is  concerned.  Where  it  is  the  dis- 
tal surface  which  needs  attention,  of  course  the  actual  filling  is  more 
difficult.  To  form  this  cavity  in  the  cuspid,  we  need  not  make  the 
labio-gingival  extension  as  deep  as  before,  but  as  there  is  abundance 
of  tooth-substance  at  the  palato-gingival  angle  we  may,  if  we  desire, 
make  the  extension  even  deeper,  though  it  is  rarely  necessary.  Again, 
as  discretion  may  dictate,  we  here  may  make  extensive  grooves  along 

Fig.  125.  Fig.  126.  Fig.  127. 


both  labial  and  palatal  borders,  and  quite  a  deep  undercut  at  the  incisive 
corner  d  is  permissible  where  requisite.  This  last  departure  from  the 
former  rigid  rule  is  allowable,  first,  because  of  the  excess  of  dentine 
in  the  cuspid  beyond  that  found  in  the  incisors,  and  second,  because 
the  pointed  cusp  of  the  cuspid  renders  fracture  of  the  corner  much  less 
liable  to  occur  than  in  the  incisor,  which  presents  a  broad,  thin  incis- 
ing edge  to  combat  the  strain  of  mastication. 

In  Fig.  126  we  see  a  cuspid  needing  a  contour  filling.  W^hen  I  state 
that  I  have  never  seen  a  cuspid  in  which  I  found  it  requisite  to  use  a 
screw,  it  is  seen  at  once  that  this  tooth  offers  a  better  field  for  extensive 
operations  than  the  incisors.  In  Fig.  126  the  full  corner  may  be  safely 
restored,  depending  entirely  upon  the  internal  arrangements.  We 
make  both  the  labio-  and  palato-gingival  extensions  deep.  We  unite 
these  with  a  deep  groove,  for  in  this  tooth  we  may  feel  comparatively 
safe  against  that  fracture  of  the  gingival  enamel,  which  makes  the 
procedure  prohibited  in  incisors.  We  make  strong  grooves  along  both 
labial  and  palatal  borders,  and  we  make  exactly  the  undercut  at  e 
which  was  forbidden  in  Fig.  iiS.  Indeed,  this  undercut  in  the 
cuspids  is  mainly  the  reliance  which  makes  us  feel  safe  without  the  use 


128  ME  THODS  OF  FIL  L ING   TEE  TIL 

of  a  screw,  and  it  is  therefore  resorted  to  in  all  cases  of  contour.  Thus 
we  find  that  the  cuspid  is  comparatively  easy  to  work  upon.  Distal 
cavities  are  often  troublesome,  especially  when  the  condition  is  what 
I  have  called  a  palato-approximal  cavity.  If  it  is  found  difficult  to 
obtain  much  separation,  which  is  not  at  all  unusual,  the  work  is  sure 
to  be  very  tedious.  Yet  even  farther  back  than  the  cuspid  region 
distal  cavities  may  be  made  to  seem  almost  like  mesial,  if  the  patient 
be  tilted  sufficiently  to  bring  the  cavity  within  range  of  the  eye,  as  is 
often  possible. 

There  is  one  cavity  which  we  sometimes  find  in  a  cuspid,  to  which  I 
may  make  special  allusion.  It  is  shown  in  Fig.  127,  where  it  is  seen 
to  occupy  a  position  along  the  neck  of  the  tooth  just  above  the  bulge 
of  the  enamel,  and  extending  around  toward  the  palatal  portion.  This 
kind  of  cavity  is  most  often  found  where  an  ill-fitting  clasp  has  been 
used  to  retain  an  artificial  denture.  Where  this  is  the  case,  the  first 
bicuspid  is  commonly  absent,  which  facilitates  the  operation.  But  let 
us  suppose  that  the  first  bicuspid  is  not  absent,  and  that  the  clasp  has 
stupidly  been  placed  between  the  two  teeth,  encircling  the  cuspid.  To 
produce  retentive  shape,  all  that  is  needed  is  to  cleanse  out  all  decay 
and  then  undercut  along  the  full  extent  toward  the  gum  and  toward 
the  incisive  edge.  At  the  palatal  end  of  the  cavity,  b,  make  a  pit 
deep  enough  to  hold  the  first  pellet  of  gold  securely  ;  in  filling,  use  the 
mirror,  and  with  hand-pressure  build  the  gold  from  that  point  well 
around  into  the  approximal  portion.  It  may  then  be  thoroughly  con- 
densed with  the  mallet,  and  the  filling  completed  as  though  only  the 
approximal  portion  had  been  involved.  Great  care  is  needed  to 
properly  polish  this  filling,  because  it  is  above  the  bulge  of  enamel. 

I  may  pass  now  to  bicuspids,  and  at  once  we  approach  an  almost  en- 
tirely different  field.  Many  dentists  claim  that  the  approximal  cavity 
in  a  bicuspid,  especially  in  the  distal  surface,  is  the  most  trying  in  the 
mouth.  Omitting  extreme  or  unusual  cases,  this  is  probably  true. 
An  evidence  of  this  is  the  fact  that  recurrence  of  decay  at  the  gingival 
border  of  fillings  is  more  often  found  in  bicuspids  than  elsewhere,  with 
the  possible  exception  of  molars,  which  are  much  the  same.  This  fact 
is  also  an  argument  that  such  recurrence  is  rather  due  to  faulty  filling 
than  to  any  idiopathic  causes  connected  with  the  position,  as  is  claimed 
by  many. 

In  general,  the  main  difficulty  is  that  it  is  harder  to  obtain  sufficient 
space.  This  is  shown  readily,  for  in  the  absence  of  the  adjacent  tooth, 
even  the  distal  approximal  cavity  in  a  bicuspid  is  really  simpler  than 
a  similar  cavity  in  an  incisor.  That  this  should  be  so  is  due  to  the  fact 
that  the  bicuspid  is  a  wide  tooth,  and  through  a  narrow  space  it  is 
often  quite  difficult  to  reach  all  parts  of  the  cavity.  When  the  bicus- 
pid happens  to  be  unusually  long,  and  the  cavity  nevertheless  reaches 


APPROXIMAL   CA  VITIES  IN  Bia  \SPIDS.  i  29 

nearly  to  the  gum  line,  the  same  difficulty  is  manifestly  increased.  I 
have  seen  teeth  of  this  nature  which  persistently  resisted  all  efforts  to 
obtain  much  space,  and  which,  containing'  extremely  large  but  shallow 
cavities,  became  excessively  tedious  in  the  filling,  because  only  very 
small  pieces  could  be  properly  carried  to  place.  Yet  we  are  told  that 
a  steel  separator  is  sufficient  for  all  purposes,  and  again  that  a  matrix 
should  be  placed  around  all  approximal  cavities  in  bicuspids  and  in 
molars  !  I  must  gi\'^e  a  few  illustrations  to  show  the  main  differences 
in  preparation  of  cavities,  from  what  has  been  already  said. 

In  Fig.  128  we  see  a  bicuspid  in  which  I  have  indicated  two  small 
cavities.  It  is  evident  that  either  of  these  would  be  simpHcity  itself 
in  the  absence  of  the  adjacent  tooth,  in  which  case  abundance  of  space 
would  give  ready  access.  In  an  ordinary  tooth  where  a  fair  separation 
is  procurable,  either  would  still  be  manageable.  With  inadequate 
space,  and  in  a  wide  tooth,  either  of  these  will  harass  both  patient  and 
operator  if  the  attempt  be  made  to  prepare  and  fill  without  extension  of 
the  cavity.  A  pellet  of  gold  crowded  between  the  teeth  will  be  so 
compressed  that  by  the  time  it  is  forced  into  the  cavity  itself  it  is  unfit 
for  use,  quickly  balling  up  so  that  it  must  be  discarded.  Again  and 
again  the  same  mishap  may  occur,  until  it  becomes  easy  to  lose  patience 
at  the  difficulty  of  filling  what  from  its  shape  alone  should  be  so  simple. 
But  with  inadequate  space  no  cavity  is  simple,  and  I  might  almost  say 
the  smaller  it  is  the  more  annoying  it  will  be.  Therefore,  in  such  cases 
I  should  recommend  extension  of  the  cavity  to  make  it  accessible. 
The  direction  of  this  extension  depends  upon  the  position.  It  should 
be  toward  the  labial  surface,  or  the  crown,  as  it  happens  to  be  nearer 
the  one  or  the  other.  For  this  reason  the  illustration  shows  two  cavi- 
ties, the  position  of  one  of  which  makes  extension 
toward  the  labial  surface  preferable,  as  shown  by  ^^^-  ^^8. 
the  dotted  lines,  whilst  in  the  other  I  would  cut 
through  to  the  crown.  The  first  practice  will  be 
resorted  to  less  frequently  in  the  mesial  than  in  the 
distal  surface,  because  of  the  probable  showing  of 
the  filling.  To  cut  through  to  the  crown  will  be 
chosen  oftener  on  either  approximal  surface.  I 
must  pause  here  a  moment  to  defend  this  propo- 
sition. It  has  been  argued  by  a  skillful  operator,  and  careful  thinker 
and  writer,  that  the  crown  of  a  bicuspid  or  molar  should  under  no  cir- 
cumstances be  disturbed  in  this  way.  An  allusion  is  made  to  the  simi- 
larity here  to  the  strength  of  an  arch.  That  is,  the  portion  of  the  tooth 
which  I  advise  removing,  this  writer  claims  is  as  the  arch  to  the  cavity,. 
and  its  greatest  protection.  A  better  argument  that  he  uses  is,  that  it 
assists  in  holding  together  the  labial  and  palatal  plates.  All  of  this  is 
beautifiil  theory  ;  but  to  my  mind  it  is  illusory,  if  not  false.     Given  a 

9 


I30  METHODS  OF  FILLING   TEETH. 

bicuspid  or  a  molar,  sound  in  other  respects,  but  having  such  a  cavity  as 
the  one  in  Fig.  128  which  is  nearer  to  the  crown,  and  the  removal  of 
enough  tooth-substance  to  reach  the  cavity  from  the  crown,  as  is  indi- 
cated by  the  dotted  lines,  leaves  us  a  tooth  with  which  one  could  eat  for 
years  without  fear  of  fracture  even  if  it  were  left  unfilled^  imagining 
for  the  sake  of  argument  that  caries  would  not  supervene.  This  being, 
as  it  is,  true,  it  follows  that  when  protected  by  a  perfect  gold  filling  the 
tooth  will  be  safe  enough.  In  the  last  statement  I  based  my  argument 
upon  mechanical  laws,  for  the  moment  forgetting  physiological  ones, 
yet  it  is  by  physiological  laws  that  the  theory  of  not  cutting  through  to 
the  crown  is  most  easily  proven  to  be  fallacious.  The  whole  aim  of  a 
filling  is  to  restore  the  depredations  of  caries  and  to  prevent  a  recur- 
rence. Granting  now  for  a  moment  that  the  cavity  is  better  made 
without  cutting  to  the  crown,  which  of  course  is  true,  yet  if  it  cannot 
be  made  fully  accessible  by  separating,  it  will  be  improperly  filled,  so 
that  caries,  which  is  not  hindered  by  mechanics,  will  be  sure  to  recur, 
and  destroy  that  arch  which  the  operator  so  thoughtfully  preserved. 
Of  course  there  are  men  so  skillful  and  so  patient  that  they  can  make 
perfect  fillings  through  the  narrowest  of  spaces.  But  these  men  are 
rare,  and  the  best  set  of  principles  is  that  which  may  be  employed  by 
the  greatest  number. 

Now,  that  I  may  not  be  misapprehended,  let  me  state  my  position 
once  more,  succinctly.  The  borders  of  a  cavity  should  never  be  ex- 
tended when  a  dentist  can  by  a  fair  expenditure  of  time  and  skill  make 
a  perfect  filling.  However,  wherever  from  lack  of  space,  or  other 
good  cause,  a  perfect  filHng  can  be  better  made  by  extension  of  the 
borders,  it  may  be  done,  and  such  extension  may  be  allowed  to  en- 
croach upon  the  crown.  Indeed,  there  are  cases  where  there  will  be 
no  other  adequate  method  of  properly  retaining  a  filling,  as  has  been 
already  shown. 

Another  point  is  pertinent  here.  Supposing  that  such  cavities  as 
shown  can  be  filled  with  amalgam  without  extension,  would  that  be 
preferable  to  extending  the  borders  and  fiUing  with  gold  ?  I  should 
decide  in  favor  of  the  gold  filling  in  every  instance.  Gold  is  always 
preferable  to  amalgaTn  for  durability,  wherever  it  can  be  inserted  pro- 
ducing  what  we  term  a  perfect  filling.     Dogmatic,  but  true. 

The  retentive  shaping  of  these  two  cavities  differs  somewhat.  In  the 
one  nearer  the  crown,  very  little  undercutting  should  be  made  alon^ 
the  labial  border,  but  a  considerable  groove  may  be  cut  along  the 
palatal,  with  a  distinct  dip  toward  the  gingival  corner  as  indicated  by 
the  dotted  fine  a.  In  the  other,  which  after  extension  will  be  filled 
through  its  labial  opening,  a  moderate  groove  toward  the  gum  and 
one  toward  the  crown  will  suffice.  At  the  palatal  end,  here  the  bot- 
tom of  the  cavity,  a  depression  may  be  made  deep  enough  to  retain 


APPRO X IMA L  CA  VITIES  IN  BICUSPIDS.  1 3  I 

the  first  pellet  immovable.     Either  of  these  cavities,  prepared  as  indi- 
cated, becomes  simple,  and  could  be  rapidly  filled  with  gold. 

In  Fig.  129  we  have  what  may  be  termed  a  simple  approximal 
cavity  in  a  bicuspid.  It  is  similar  to  Fig.  112,  where  it  is  shown  in 
a  central.  Its  preparation  here  is  different.  We  no  longer  need  deep 
labio-  and  palato-gingival  extensions,  nor  are  we  compelled  to  avoid 
labial  and  palatal  grooving.  In  the  bicuspid  we 
have  simply  a  cavity  surrounded  by  strong  walls.  ' 

Any  antagonizing  retaining  arrangement  will 
serve  to  hold  the  filling  in  place.  The  choice, 
therefore,  must  depend  upon  attendant  circum- 
stances. Where  the  adjacent  tooth  is  missing, 
a  moderate  groove  forming  an  undercut  all 
around  will  prove  the  simplest  and  best.  Where 
there  is  an  adjacent  tooth  and  we  must  work  at 
the  disadvantage  of  having  the  cavity  more  or  less  inaccessible,  we 
may  best  proceed  otherwise.  The  most  universally  useful  arrange- 
ment will  be  as  follows  :  make  a  palato-gingival  extension,  not  too 
deep,  but  shaped  so  as  to  retain  the  first  pellet,  as  indicated 
at  a.  Make  a  similar  depression  toward  the  crown  at  the  palatal 
corner,  as  seen  at  b.  Connect  the  two  by  a  fairly  deep  groove 
along  the  palatal  border.  A  rose  bur  run  around  the  rest  of  the 
cavity  borders,  making  a  general  but  not  deep  groove,  gives  us  a 
strong  cavity  readily  filled.  To  place  the  gold,  begin  in  the  palato- 
gingival  extension,  and  having  securely  anchored  the  gold  at  that 
point,  build  along  the  palatal  groove  and  also  along  the  gingival  bor- 
der simultaneously,  being  careful  not  to  advance  either  too  rapidly, 
lest  the  excess  of  gold  placed  at  one  point  make  the  other  inaccessi- 
ble. This  is  a  very  important  factor  in  the  successful  filling  of  a 
bicuspid.  It  will  be  seen  that  by  following  this  plan  we  finally  come 
to  a  point  where  the  labial  corner  at  c  must  receive  attention.  Es- 
pecially where  the  labial  border  of  the  cavity  is  at  some  distance  from 
the  labial  surface  proper,  any  undercutting  at  this  part  becomes  quite 
■difficult  to  fill,  and  the  most  unmanageable  point  of  all  would  be  at  f, 
so  that  as  we  approach  this  place  we  must  use  greater  caution.  It 
must  be  filled  before  the  gold  has  been  brought  so  close  that  we  have 
inadequate  room  to  reach  it ;  and  yet  in  packing  gold  into  this  corner, 
if  we  at  once  build  it  out  to  the  edge  of  the  cavity,  we  will  find  it  diffi- 
cult to  fill  the  hollow  which  will  have  been  left  behind  along  the  sur- 
face of  the  gold.  More  than  likely  when  we  come  to  polish  the  filling 
we  will  find  an  ugly  pit,  caused  by  an  insufficiency  of  gold.  The 
remedy  is  simple,  but  requires  patience.  Though  for  the  bulk  of 
the  filling  we  may  have  been  using  fairly  large  pellets,  as  soon  as  we 
arrive  at  this  corner  we  must  choose  smaller  pieces  of  gold  and  build 


132  METHODS  OF  FILLING   TEETH. 

slowly.  Strictly  speaking,  we  should  have  been  using  heavy  foil  only, 
for  some  time  previous  to  reaching  this  place.  To  fill  the  actual 
corner  we  should  select  small  pellets,  and  as  soon  as  these  have 
brought  the  filling  about  half-way  from  the  bottom  of  the  cavity  to  the 
margin,  we  should  return  to  heavy  foil,  which  because  of  its  form 
is  peculiarly  adapted  to  our  needs  here.  With  it,  by  proper  manipu- 
lation, a  filling  should  result  which  would  be  without 
Fig.  130.  a  flaw. 

Fig.  130  shows  a  common  form  of  cavity,  such 
as  is  sometimes  termed  a  compound  cavity,  be- 
cause it.  occupies  both  crown  and  approximal  sur- 
faces.    The  arrangement  for  retention  is  precisely 

I J  similar  to  the  last,   except  that,   as  we  now  have 

an  anchorage  in  the  crown,  we  need  not  make 
the  deep  undercut  at  b.  As  before,  c  becomes  a 
point  of  interest,  greater  here  than  in  the  last  condition.  If  left  as 
pictured,  with  a  narrow  passage  connecting  approximal  and  crown, 
the  resulting  sharp  corner  will  give  considerable  trouble.  The- 
similar  angle  on  the  palatal  side  will  not  be  as  bad,  though  even  there 
it  may  be  trimmed  down  with  advantage.  At  r,  however,  the  labial 
angle  should  be  removed  as  indicated  by  the  dotted  line,  which,  if 
studied,  will  be  seen  to  follow  the  natural  curve  of  the  labial  border 
line.  When  filling  this  cavity,  as  in  the  last  case,  this  part  will  need 
extra  care.  Supposing  that  all  has  advanced  as  in  the  last,  the  best 
plan  will  be  to  give  attention  to  the  part  of  the  cavity  occupying  the 
crown,  and  fill  that  thoroughly  without  special  reference  to  the  approx- 
imal portion.  This  done,  we  have  reduced  the  case  to  exactly  what 
we  had  in  the  last  cavity  when  we  came  to  fill  c,  and  consequently 
can  now  proceed  as  then.  Should  we  attempt  to  fill  c  before  attend- 
ing to  the  crown,  we  would  find  it  very  troublesome.  In  fact,  it  would 
be  necessary  to  alternate  between  the  approximal  and  the  crown, 
causing  much  annoyance,  especially  as  it  often  happens  that  the  posi- 
tion of  the  patient  must  be  altered  so  as  better  to  see  one  or  the  other. 
To  fill  the  crown  first,  simplifies  the  operation,  and  is  therefore  prefer- 
able. In  these  extensive  approximal  cavities,  the  gingival  border  is 
always  a  most  trying  obstacle  to  success.  To  obtain  a  perfect  margin 
to  these  cases  is  as  difficult  as  it  is  essential.  I  rarely  make  a  deep 
groove  or  undercut  here,  but  rather  aim  to  leave  the  margin  strong 
and  very  slightly  beveled.  More  strictly  speaking,  instead  of  beveled 
— a  word  usually  applied  to  the  extreme  edge  of  a  cavity — I  should 
say  that  I  form  it  continuous  with  the  floor  of  the  cavity.  This  allows 
the  placing  of  a  fairly  large  pellet  of  gold,  which,  attached  to  that 
already  secured  in  the  palato -gingival  extension,  may  be  laid  against 
and  lapped  over  this  gingival  margin,  and  partly  condensed  by  hand- 


APPROXIMAL   CA  I  '/TIES  I.V  P.ICl  'SP/PS.  i  33 

pressure,  using  a  foot-plugger.  Next  I  cover  this  with  a  piece  of  No. 
60  gold  and  mallet  it  down,  again  using  the  foot  instrument.  By  this 
method  the  whole  border  is  well  and  rapidly  covered,  the  under  pellet 
serving  as  a  soft  cushion  which  easily  adapts  itself  to  irregularities 
under  the  mallet-stroke,  while  the  heavy  foil  is  stiff  enough  to  hold  all 
in  place  as  it  is  condensed. 

As  with  incisors,  the  palato-approximal  cavity  is  more  difficult  in  a 
bicuspid  than  the  labio-approximal.     I  may  therefore  better  choose 
the  latter  for  an  illustration  to  show  in  what  its  management  differs 
from  that  advocated  in  the  incisor  region.     Fig. 
131  shows  a  bicuspid  having  such  a  cavity.     There  Fig.  131. 

might  be  circumstances  under  which  I  should  use 
a  screw  here,  but  when  we  remember  that  this  po- 
sition is  inaccessible,  and  that  a  screw  renders  any 
case  more  trying,  it  is  plain  that  only  extreme 
necessity  would  urge  its  adoption.  The  main 
reliance  here  will  be  to  resort  once  more  to  labio- 
and  palato-gingival  extensions,  as  shown  at  a  and 
d.  I  should  not  make  much  of  a  groove  under 
the  labial  wall,  but,  passing  from  the  palato-gingival  extension,  I 
should  make  a  slight  groove  along  the  palatal  border,  deepening  it 
as  I  approached  the  crown,  till  at  c  it  became  a  distinct  concavity. 
Whether  caries  has  involved  the  crown  or  not,  the  sulcus  must  be  cut 
out  across  to  its  opposite  extremity,  and  at  that  point  a  deep  retaining- 
pit  should  be  made  as  advocated  and  illustrated  by  Fig.  28,  shown 
also  less  distinctly  in  the  present  figure  at  d.  In  some  instances,  pos- 
sibly because  of  extreme  sensitiveness,  or  perhaps  from  the  poor  shape 
of  the  tooth,  only  very  slight  retentive  shape  may  be  attainable  along 
the  gingival  part  of  the  cavity.  This  would  necessitate  a  proportion- 
ate deepening  of  the  palatal  groove  and  the  formation  of  a  more 
distinct  one  under  the  labial  wall,  care  being  taken  not  to  so  under- 
mine it  as  to  weaken  it.  I  should  call  attention  here  to  the  fact  that 
these  directions  exactly  contradict  those  given  for  the  same  cavities  in 
the  incisors.  There  the  groove,  when  made  at  all,  was  along  the 
wall  left  standing,  while  in  bicuspids  I  direct  that  it  shall  be  made 
along  that  side  where  the  greatest  loss  has  occurred.  The  latter  prin- 
ciple is  the  more  correct,  but  it  is  inapplicable  in  the  incisor,  for  there, 
there  will  not  be  found  sufficient  space  in  which  to  make  a  groove, 
which,  if  it  escape  the  pulp,  will  not  leave  the  enamel  which  it  under- 
mines so  weak  that  it  adds  nothing  to  the  strength  of  the  cavity.  In 
the  bicuspid  it  is  different.  Even  were  the  palatal  part  of  theapprox- 
imal  surface  removed  till  we  reach  a  plane  in  line  with  the  center  of 
the  pulp,  owing  to  the  width  of  the  tooth  we  could  still  always  cut  a 
groove  which  would  make  a  strong  retaining  formation,  as  seen  in 


134 


METHODS  OF  FILLING   TEETH. 


Fig.  131  at  and  between  b  and  c.  In  filling  these  cavities  the  usual 
method  as  described  in  the  previous  cases  would  be  followed,  save 
that  we  should  build  against  the  labial  wall  before  the  palatal.  But 
in  the  exceptional  cases  described,  where  we  get  but  poor  retentive 
shape  along  the  approximal  part  of  the  cavity,  we  might  find  it  better 
to  begin  in  the  retaining-pit  in  the  crown  and  build  over  and  into  the 
approximal  part,  as  has  been  alluded  to  in  the  description  of  the  use 
of  heavy  foil. 

In  making  contour  fillings  in  bicuspids  where  the  cavity  is  similar 
to  that  in  a  cuspid,  shown  in  Fig.  126,  no  special  change  of  plan  is  to 
be  made,  save  that  where  there  we  had  a  single  undercut  in  the  end 
of  the  cusp  at  e,  in  a  bicuspid  we  may  have  one  in  each  cusp,  and  be- 
side resort  to  the  retaining-pit  in  the  sulcus,  as  in  the  last  figure. 

I  may  now  pass  to  molars,  which,  though  in  many  respects  similar  to 
bicuspids,  still  present  some  points  of  difiference.  Usually  there  is  so 
much  tooth-substance  in  all  directions  that  we  may  almost  make  the 
rule  that  in  each  given  case  we  shall  decide  according  to  the  conveni- 
ences, and  possible  dangers  of  exposing  the  pulp.  In  molars  more 
than  in  any  other  teeth  we  should  be  always  cognizant  of  the  fact  that 
the  youjiger  the  tooth  the  larger  the  pulp.  I  remember  that  once  in  a 
first  superior  molar  in  the  mouth  of  a  miss  of  twelve,  I  found  an  expos- 


FiG.  132. 


Fig.  133. 


Fig.  134. 


ure  of  the  pulp  in  a  cavity  so  shallow  that  without  alteration  it  would 
not  have  retained  a  gutta-percha  filling.  Per  contra,  late  in  life  we 
often  see  molars  in  which  the  most  extensive  undercutting  may  be 
attempted  with  little  danger. 

On  general  principles  I  may  say  that  in  approximal  cavities  in 
molars  I  depend  chiefly  upon  two  opposing  grooves.  I  prefer  that 
these  should  lie  along  the  buccal  and  the  palatal  borders,  but  under 
some  circumstances  they  would  be  situated  otherwise.  Such  a  con- 
dition is  shown  in  Fig.  132,  in  which  we  observe  a  narrow  cavity 
extending  along  the  gum-line  and  partly  around  the  buccal  surface. 
Such  cavities  often  result  from  the  use  of  ill-fitting  clasps,  though  they 
may  occasionally  occur  where  no  clasps  or  bands  have  been  used.  Here 
we  have  a  condition  practically  similar  to  one  of  the  cavities  in  the. 


APPROXIMAL  CA  VITIES  IN  MOLARS.  \  35 

bicuspid  at  Fig.  12S.  The  filling- may  be  retained  by  grooves  along 
the  borders  at  a  and  b,  and  the  gold  may  be  introduced  readily  with 
even  a  small  space,  being  passed  in  at  the  buccal  aspect.  Where  a 
similar  cavity  encroaches  upon  the  palatal  surface,  it  is  much  more 
difficult.  If  the  tooth  be  on  the  left  upper  side  of  the  jaw,  I  turn  the 
patient's  head  so  that,  looking  across  the  roof  of  the  mouth,  I  may 
see  into  the  cavity  through  its  palatal  extension,  and  I  place  the  first 
pellet  through  this  aperture,  packing  it  into  the  extreme  buccal  end. 
From  this  I  build  toward  and  finish  at  the  palatal  part.  On  the  right 
side  I  follow  the  same  general  rule,  save  that  here  one  must  resort 
more  to  the  mouth-mirror.  In  the  lower  jaw  all  is  different.  To  fill 
with  gold  with  any  hope  of  success,  the  widest  possible  separation  is 
needed,  and  even  then  it  will  often  be  found  difficult,  if  not  impossible, 
to  pack  the  gold  properly  should  the  tooth  be  long.  If  the  cavity  in 
addition  should  be  on  the  distal  surface,  it  will  be  trebly  troublesome. 
Therefore,  where  I  decide  to  use  gold,  I  most  often  extend  the  cavity 
toward  the  crown,  as  shown  in  Fig.  133,  in  extreme  cases  even  cutting 
through  to  the  crown  proper.  Where  such  extension  is  decided  upon 
I  do  not  make  much  of  a  groove  along  the  gingival  border  a,  but  I 
make  a  linguo-gingival  extension  at  (5,  at  which  point  I  start  the  filling, 
and  place  grooves  along  the  borders  at  c  and  d,  of  decreasing  depth 
as  they  approach  the  crown. 

Fig.  134  shows  a  very  unpleasant  condition.  It  is  what  we  term  a 
saucer-shaped  approximal  cavity,  in  a  molar.  Where  the  dentine  is 
very  sensitive,  we  often  find  it  almost  impossible  to  obtain  any  anchor- 
ages along  the  gingival  border,  and,  strictly  speaking,  it  is  not  needed, 
for  the  filling  can  be  perfectly  retained  without  disturbing  this  part  of 
the  tooth  other  than  to  cleanse  it  of  all  decay.  Once  more  I  should 
depend  upon  lateral  grooves  along  the  buccal  border,  and  the  palatal, 
or  lingual  if  it  be  the  lower  tooth.  But  these  grooves  would  be  the  re- 
verse of  those  in  Fig.  133.  There  they  were  deepest  nearer  the  gingival 
portion.  Now  I  should  begin  by  making  an  extension  into  the  crown 
as  shown  at  a,  with  lateral  wings  or  dovetails  indicated  at  b,b.  From 
these  dovetails  I  would  carry  my  grooves  deep  into  the  tooth-sub- 
stance, decreasing  the  depth  until  they  emerged  at  d,d.  Between  these 
points  ^,^we  have  the  gingival  border  c,  which  I  have  said  may  be  the 
most  sensitive  part  of  the  dentine,  and  we  need  no  undercutting.  But 
where  the  dovetailing  into  the  crown  would  lea\'e  the  lateral  walls  weak, 
then  we  will  simply  be  forced  to  abandon  that  plan,  making  the  lateral 
grooves  as  deep  as  consistent  with  strength,  and  forming  a  gingival 
groove  as  far  as  we  are  enabled. 

Fig.  135  shows  the  loss  of  the  buccal  corner  as  well  as  the  palatal, 
so  that  a  full  contour  is  required.  Where  only  one  corner  is  absent, 
the  filling  may  be  anchored  chiefly  into  a  deep  undercut  into  that 


136 


METHODS  OF  FILLING   TEETH. 


which  remains  standing  ;  but  where  both  are  absent,  as  in  the  figure, 
the  retaining  arrangement  is  sufficiently  unique  to  excuse  a  special 
description.  I  should  make  a  gingival  groove  ending  in  deep  dips  at 
each  end,  similar  to  the  palato-  and  labio-gingival  extensions  alluded 
to  in  other  cases.  From  these  I  should  extend  grooves  toward  the 
crown,  as  shown  at  «,  a.  It  is  the  formation  of  these  which  is  unique. 
I  take  a  rose  bur  first,  and  make  the  groove  as  deep  as  determined  ; 
then  I  follow  with  a  wheel  bur  larg-er  than  the  diameter  of  the  rose 


Fig.  135. 


Fig.  136. 


bur.  This  wheel,  passing  from  end  to  end  of  each  groove,  forms  a 
lateral  undercut  in  each,  which  must  be  made  deepest  toward  the 
pulp.  To  better  illustrate  the  idea  I  introduce  Fig.  136,  which  is  a 
section  through  the  center  of  a  filling  placed  in  such  a  cavity.  The 
approximal  surface  is  shown  at  b,  whilst  a,  a  indicates  that  part  of  the 
filling  which  occupied  the  grooves.  In  addition  to  these  retainers,  if 
considered  necessary,  an  extension  may  be  made  across  the  crown  and 
into  the  opposite  sulcus,  as  already  described  in  discussing  bicuspids. 


CHAPTER    VI. 

Special  Principles  involved  in  the  Preparation  of  Cavities  and 
THE  Insertion  of  Fillings — Cavities  in  the  Masticating  Surfaces 
— Incisors— Treatment  of  Imperfections — Of  Fractures — Of  Abra- 
sions— Of  Malformations — Cuspids— Bicuspids — Molars — Oxyphos- 
phates  in  Combination  with  Gold — Uniting  Teeth  by  Bar  and 
Filling. 


I  NOW  come  to  the  consideration  of  cavities  in  the  incisive  edges  of 
incisors  and  cuspids,  and  the  masticating  surfaces  of  bicuspids  and 
molars. 

Strictly  speaking,  a  cavity  in  the  incisive  ^6.^^  of  an  incisor  is  a 
rarity,  less  so  in  the  inferior  than  in  the  superior  teeth.  In  making 
this  statement  I  do  not  include  abraded  teeth,  but  refer  to  such  only 


CA I  'I TIES  IN  THE  MAS  TICA  TING  SURFA  CES.  1 3 ; 

as  have  suffered  no  other  depredation  at  this  part.  I  have  seen  a  few 
cases  where  a  distinct  cavity,  truly  carious  in  character,  has  presented, 
seen  along  the  incisive  edge  only,  and  not  involving  either  labial  or 
palatal  surface.  They  are  found  in  the  form  of  tiny  dark  spots,  into 
which  the  fine  point  of  an  explorer  readily  passes,  sometimes  to  a 
considerable  distance.  Such  a  cavity  probably  has  its  inception  in  an 
imperfection  in  the  enamel,  a  tiny  pit  offering  a  suitable  starting-place 
for  caries.  To  prepare  these,  it  is  only  necessary  to  remove  the  decay 
thoroughly,  care  being  observed  not  to  split  off  the  enamel  along 
either  surface,  thereby  producing  a  fracture  which  would  necessitate 
an  awkward  and  unsightly  filling.  To  fill,  use  gold,  in  tiny  pellets, 
or  better  still  depend  upon  crystal.  When  completed  it  should  ap- 
pear as  a  small  polished  gold  dot. 

I  have  seen  caries  along  the  full  length  of  the  edge  of  a  central 
incisor,  appearing  as  a  black  line  and  extending  to  a  considerable 
depth.  When  all  the  decay  is  removed  from  such  a  cavity,  no  spe- 
cial alteration  of  shape  is  needed  to  achieve  retention.  The  depth, 
in  connection  with  the  narrowness  of  the  fissure,  and  the  roughness 
of  the  walls,  will  prove  sufficient.  To  fill  with  gold,  a  convenient 
method  is  to  select  a  pellet  about  the  length  of  the  groove,  and  just 
thick  enough  so  that  it  must  be  slightly  compressed  as  it  passes  the 
orifice  ;  this  is  an  exception  which  marks  the  difference  between 
general  and  special  principles.  Suppose,  however,  that  such  a  cavity 
should  present,  the  caries  having  proceeded  only  to  a  slight  depth. 
Then  the  groove  would  not  be  deep  enough  to  retain  the  filling. 
Should  it  be  deepened  ?  To  do  so  would  be  unwise.  While  we  must 
accept  the  condition  as  it  is  found  in  the  first  instance,  we  must  not 
reproduce  it  in  the  second,  even  though  it  be  an  effectual  retentive 
shape.  To  deepen  the  cavity  would  be  to  render  the  labial  and 
palatal  walls  weaker,  and  make  more  probable  the  subsequent  split- 
ting off  of  the  one  or  the  other.  Such  an  accident  would  be  espe- 
cially likely  to  occur  in  the  mouth  of  a  woman, 
for  despite  constant  precautions,  women  will  bite  Fig.  137. 

off  threads  with  their  teeth.  The  cavity  is  shown 
in  Fig.  137 .  It  is  prepared  with  a  tiny  rose  bur, 
and  retention  depends  upon  a  slight  dip  into  the 
dentine  at  each  end  of  the  cavity,  a  and  b.  It 
is  evident  that  this  makes  the  filling  after  inser- 
tion just  a  trifle  longer  within,  than  at  the  orifice, 
which  is  all  sufficient.  To  fill  with  gold  we 
must  proceed  differently  to  the  method  advo- 
cated in  the  deep  groove,  where  I  said  we  might  start  with  a  long 
pellet.  Here  it  is  better  to  begin  at  one  end,  and  build  across  to 
the  opposite  pit  with  small  pellets.     As  soon' as  the  floor  is  thus 


138  METHODS  OF  FILLING   TEETH. 

covered,  and  the  retaining-points  "connected,  the^  filling  must^be 
completed  with  heavy  gold  cut  into  very  narrow  strips,  about  as 
long  as  the  cavity.  The  finest-pointed  plugger,  and  the  hand- 
mallet,  will  give  us  a  filling  which  will  keep  its  density  of  surface 
forever.  It  is  the  filling  of  such  cavities  as  these  which  show  whether 
the  dentist  is  an  artist  or  merely  a  mechanic.  They  are  so  accessible, 
and  apparently  so  easy,  that  I  have  seen  many  men  at  clinics  select 
them  for  demonstrating  rapid  work.  Yet  rapid  work  here  means  the 
use  of  too  large  pieces  of  gold,  and  imperfect  condensation  of  the 
gold,  with  the  result  that  after  moderate  usage  the  gold  becomes  rough. 
The  same  system  practiced  where  the  entire  edge  is  covered  brings 
the  fining  back  with  a  ragged  edge  turned  up,  as  is  seen  on  the  ferrule 
of  a  cane  or  umbrella. 

Sometimes  we  find  an  incisor  presenting  with  a  brownish  spot 
which  may  occur  so  as  to  involve  the  incisive  edge.  Immediately 
upon  eruption,  though  the  tooth-substance  is  imperfectly  calcified, 
yet  it  is  protected  to  some  extent  by  the  fact  that  there  is  a  superficial 
crust  which  is  more  dense  than  what  underlies  it.  After  a  few  years 
this  crust  may  break  down,  and  filling  become  necessary.  It  is  wiser 
to  remove  all  of  this  imperfection,  as  the  dentine  will  be  found  to  be 
chalky.  Where  only  the  labial  plate  of  enamel  is  involved,  the 
presence  of  the  palatal. renders  the  cavity  more  simple.  I  will  there- 
fore choose  for  illustration  such  a  cavity,  the  preparation  of  which 
has  required  the  removal  of  a  part  of  both  surfaces.  Fig.  138  shows 
the  cavity  in  a  central  incisor  prepared  for  filling.  After  removing 
all  of  the  defective  dentine,  the  first  step  toward  retention  is  to  make 
a  rather  shallow  groove  along  the  whole  extent,  nearly  the  full  width 
of  the  dentine  and  not  encroaching  upon  the  enamel.  This  direction 
analyzed  is  found  to  indicate  that  this  groove  is  narrower  as  it 
approaches  the  incisive  edge.  It  is  at  once  seen  that  already  the 
shape  is  retentive,  since  the  filling  would  be  wedged  in  laterally.  It 
would  be  difficult,  however,  if  not  impossible,  to  successfully  fill  the 
cavity  so  formed,  because  there  is  no  starting-place.  Moreover, 
should  any  accident  in  the  future  fracture  either  of  the  frail  corners, 
the  entire  filling  would  be  lost,  and  a  difficult  operation  be  entailed 
for  the  restoration  of  the  tooth.  I  have  in  mind  a  case  where  I  filled 
both  superior  central  incisors,  having  cavities  of  this'  nature.  Some 
years  later  the  lady  called  with  the  distal  corner  of  one,  lost  by  frac- 
ture, and  I  was  able  to  build  on  a  contour  without  removing  the 
original  filling.  For  a  firm  anchorage,  therefore,  form  a  dovetail  by 
extensions  in  the  directions  indicated  by  a,  a,  in  either  of  which  the 
filling  may  be  readily  started,  the  arrangement  being  of  such  form  as 
will  retain  the  first  pellet. 

It  is  opportune  at  this  point  to  indicate  how  to  proceed  should  the 


TREATMENT  OE  FRACTURES. 


139 


accident  occur  to  which  I  have  referred,  the  tooth  coming  back  with 
one  corner  missing.  It  will  usually  appear  as  shown  in  Fig.  139, 
where  we  see  the  retentive  shaping  as  before  indicated  by  the  dotted 
line  a,  a,  the  filling  itself  now  observed  at  b.  The  distal  corner  is 
absent.  A  study  of  this  illustration  will  bring  us  to  the  conclusion 
that  the  loss  of  the  corner  has  not  impaired  the  integrity  of  the  filling. 
Of  course  had  the  fracture  occurred  higher  up,  let  us  say  on  a  line 
with  a,  the  gold  would  need  removal.  But  the  most  probable  pre- 
sentment is  as  indicated.  How  shall  we  proceed?  Very  little  is  to  be- 
done  to  the  tooth  itself,  the  main  reliance  being  upon  dovetailing  into 
the  gold  filling.  Fig.  140  gives  an  idea  of  the  new  cavity  ready  for 
filling.  The  sharp  angle  left  by  the  fracture  has  been  removed  so  that 
the  completed  filling  will  be  more  sightly.  A  small  rose  bur  has  been 
passed  to  the  upper  end  of  the  extension  at  a,  and  from  this  point  a 
groove  formed  as  indicated  by  the  dotted  line  c.  A  deep  undercut 
has  been  made  into  the  gold  filling,  as  shown  by  the  dotted  line  d. 

Fig.  138.  Fig.  139.  Fig.  140. 


This  undercut  is  made  with  a  bur,  and  the  gold  into  which  the  under- 
cutting is  carried  may  be  advantageously  left  rough.  It  is  even  possible 
by  thorough  drying  to  produce  an  approximation  of  cohesion  between 
the  new  and  the  old  gold,  but  this  is  not  essential,  as  a  sufficiently 
strong  mechanical  union  occurs  by  careful  filling.  The  first  bit  of 
gold  may  be  placed  in  the  extension  at  a,  and  crystal  will  be  found  to 
serve  admirably  to  begin  with. 

I  will  relate  an  incident  which  will  better  convey  the  importance  of 
properly  filling  the  next  cavity  which  I  am  about  to  describe,  than 
any  mere  words  of  caution.  A  child  of  fourteen  whom  I  saw  occa- 
sionally, but  who  was  not  in  my  care,  fell  and  splintered  ofi"  a  portion 
of  the  cutting-edge  and  labial  face  of  the  enamel  of  a  central  incisor, 
making  a  cavity  which  could  have  been  prepared  proportionately  as 
shown  in  Fig.  141.  She  was  taken  to  her  family  dentist,  and  when  I 
next  saw  the  girl  a  gold  filling  had  been  inserted  of  about  'the  size  indi- 
cated. I  asked  permission  to  look  at  the  tooth,  but  after  examination 
made  no  comment,  satisfied  that  any  adverse  criticism  would  have 
been  counted  professional  jealousy.      About  two  years  later,  having 


140  METHODS  OF  FILLING   TEETH. 

seen  little  of  the  girl  in  the  interim,  I  met  her,  and  my  glance  at  once 
wandered  toward  that  filling,  which  I  noticed  had  grown  to  about  the 
size  indicated  by  the  dotted  line  c  in  Fig.  141.  Questioning  elicited 
the  information  that  the  cavity  had  been  refilled  three  times,  each 
operation  enlarging  the  area  of  gold.  The  last 
Fig.  141.  fining,  though  a  poor  one,  has  remained  in  place, 

but  the  young  lady  is  disfigured  for  life,   or  as 
long  as  she  retains  the  tooth. 

When  a  patient  presents  with  a  fracture  of 
this  nature,  the  first  care  of  the  dentist  should 
be  to  examine  carefully  in  order  to  determine 
whether  the  dentine  has  been  denuded  at  any 
place.  If  not,  it  often  occurs  that  the  fracture 
may  be  stoned  down  and  polished,  even  where  there  may  be  a  con- 
siderable concavity,  making  a  much  more  presentable  appearance 
than  after  the  insertion  of  gold.  The  concavity  may  be  made  less 
conspicuous  by  the  judicious  beveling  of  the  labial  surface  near  the 
incisive  edge.  Even  where  the  dentine  has  been  uncovered,  I  have 
sometimes  polished  it  and  so  left  it,  whilst  in  other  cases  where  this 
seemed  inadvisable  I  have  first  ground  down  the  tooth,  as  directed, 
as  far  as  could  be  done  with  safety,  and  then  prepared  and  filled  that 
part  where  the  dentine  had  become  exposed.  Thus  it  is  seen  that  the 
aim  should  always  be,  first,  to  avoid  filling  at  all,  and  second,  to  make 
the  cavity  as  limited  as  possible. 

Where  the  fracture  is  so  deep  that  a  filling  is  peremptorily  demanded, 
only  the  finest  of  burs  should  be  used  in  forming  the  cavity.  I  should 
recommend  that  drills  be  avoided,  as  tending  to  shiver  and  split  the 
enamel.  A  new  rose  bur  is  safest  and  best.  The  first  step  will  be  to 
use  the  corundum,  polishing  down  what  need  not  be  included  in  the 
cavity  proper,  and  sharpening  and  perfecting  the  border  lines  decided 
upon.  Next,  with  the  rose  bur,  cut  a  tiny  groove  around  the  semi- 
circle, making  it  deeper  laterally  at «,  a  in  Fig.  141,  and  deepest  at  the 
mesial  and  distal  corners  b^  b.  This  cavity  should  be  first  floored  over 
with  the  tiniest  of  pellets,  and  then  completed  with  heavy  foil  not 
heavier  than  No.  30,  cut  into  quite  small  pieces.  Small  points  are 
needed,  and  light  taps  of  a  hand-mallet.  Such  a  place  as  this  is 
a  good  one  in  which  to  avoid  a  power-mallet  of  any  kind. 

In  order  to  make  more  clear  the  fact  that  this  plan  avoids  the 
danger  of  disaster  such  as  occurred  in  the  case  described  previously, 
I  must  point  out  the  difference  in  the  arrangement. 

When  I  examined  the  first  filling  which  had  been  placed  in  the 
child's  tooth,  had  I  criticised  it  I  should  have  called  attention  to  the 
following  facts,  as  indicative  of  future  failure  :  The  surface  of  the  gold 
was  pitted,  showing  that  it  was  not  densely  packed.     Yet  other  work 


TREA  TMENT  OF  ERA  CTURES.  \ 4  r 

by  the  same  dentist  proved  that  he  knew  how  to  pack  gold.  The 
reason  of  his  failure  to  do  so  here  was  seen  as  soon  as  the  borders  of 
the  cavity  were  examined  closely.  All  around  the  semicircle  the 
gold  could  be  seen  showing  through  the  thin,  transparent  enamel, 
whilst  the  enamel  itself  showed  minute  cracks,  such  as  would  appear 
in  a  bit  of  china  or  glass  first  heated  and  then  dropped  into  cold 
water.  The  probability  is,  that  whilst  packing  his  gold  the  dentist 
noted  that  his  borders  were  breaking  down,  and  deciding  that  it  was 
the  fault  of  the  tooth-structure,  he  felt  obliged  to  use  either  a  lighter 
mallet-stroke,  or  else  to  depend  entirely  upon  hand-pressure.  The 
truth  is,  the  whole  fault  lay  in  the  preparation  of  the  cavity,  and  in 
showing  this  I  will  indicate  to  the  student  a  cause  which  is  productive 
of  a  large  proportion  of  failures  along  the  margins  of  fillings.  What 
this  dentist  had  neglected  to  observe,  if  expressed  as  an  axiom, 
would  read,  '  ''As  far  as  possible,  avoid  placing  gold  m  contact  with 
the  dentinal  szcrface  of  enamel^  In  the  preparation  of  all  cavities, 
it  should  be  the  constant  care  that  in  undercutting,  some  dentine  be  left 
in  contact  with  the  enamel.  In  the  case  under  consideration  the 
dentist  had  made  a  deep  groove  all  around  his  semicircle,  and  had 
entirely  removed  the  dentine  from  beneath  the  enamel.  Thus  as  soon 
as  he  packed  gold  into  the  grooves,  especially  where  he  attempted  to 
use  the  mallet,  his  gold  acted  as  a  wedge  to  lift  the  enamel,  and, 
being  extremely  brittle,  it  will  never  endure  this.  Yet  I  have  myself 
recommended  a  groove.  But  observe  that  I  say  ' '  only  the  finest  of 
burs  should  be  used,"  and  as  to  the  groove  itself,  my  description  is, 
"With  a  rose  bur  cut  a  tiny  groove  around  the  semicircle,  making  it 
deeper  laterally  at  a,  a  in  Fig.  141,  and  deepest  at  the  mesial  and 
distal  corners  b,  b.''  By  ' '  laterally' '  in  the  above  sentence  I  mean 
simply  at  the  sides  of  the  cavity,  and  do  not  use  the  word  to  describe 
the  formation  of  the  groove  except  as  to  depth.  I  would  not  make  this 
groove  horizontally,  but  rather  obliquely,  dipping  i-nward  toward  the 
dentine.  At  the  corners  b,  b  this  dip  should  be  more  pronounced,  as 
here  we  are  in  safer  territory,  can  reach  stronger  dentine,  and  must 
depend  most  for  the  retention  of  the  filling. 

In  one  more  important  essential  had  the  dentist  erred.  He  con- 
toured the  edge  of  his  filling,  restoring  the  incisive  edge  to  its  original 
shape,  or  made  it  more  square  by  use  of  his  corundum.  When  it  is 
remembered  that  almost  every  morsel  of  food  passed  into  the  oral 
cavity  is  first  cut  off  with  the  incisors,  it  is  plain  that  much  strain  must 
come  upon  this  weak  spot.  Where  the  filling  is  left  square  at  the 
incisive  edge,  it  becomes  a  lever  which  tends  to  dislodge  the  gold. 
Therefore  in  finishing  such  a  filling  it  is  always  wise  to  round  off  the 
edge  thoroughly,  even  though  it  be  necessary  to  dress  down  the  full 
width  of  the  tooth  along  the  labial  edge. 


142  METHODS  OF  FILLING   TEETH. 

Next  we  come  to  abrasions.  When  seen  in  the  earlier  stages  the 
■edges  of  the  incisors  present,  worn  off  on  an  obhque  plane,  the  den- 
tine being  exposed  and  cupped  out  so  that  it  appears  as  a  marked 
depression  or  concavity.  At  first  this  concavity  is  puzzling.  We 
appreciate  the  fact  that  the  opposite  or  occluding  tooth  is  the  main 
factor  in  the  depredation,  yet  when  brought  together  the  oiTender  by 
no  means  fits  into  the  grooved  dentine.  Some  have,  from  this  argu- 
ment, claimed  that  all  these  concavities  in  the  masticating  surfaces  of 
teeth  are  results  of  erosions.  This  is  most  probably  an  error.  They 
are  abrasions,  and  are  accounted  for  by  the  fact  that  the  food  which 
is  chewed  plays  a  part  in  the  destruction.  As  long  as  the  end  of  the 
tooth  is  protected  by  enamel,  the  abrasion  goes  on  horizontally  ;  the 
occluding  tooth  accurately  fits  into  the  abraded  surface.  JSfo  concavity 
in  the  enamel  appears.  This  iri  itself  is  sufficient  to  eliminate  the  idea 
of  erosio7i,  for  erosions  invariably  form  concavities  in  the  enamel 
before  the  dentine  is  exposed,  whilst  after  it  is  exposed  there  is  no 
viore  viarked  concavity  in  the  dentine  than  in  the  enamel,  the  whole 
presenting  a  single  continuous  cupping.  The  contrary  is  true  with 
abrasion.  As  soon  as  the  dentine  is  reached  the  concavity  begins  to 
appear,  becoming  greater  and  greater  as  the  dentine  is  wasted  away. 
The  cause  is,  that  the  friction  from,  the  food  causes  a  more  rapid 
wearing  away  of  the  dentine  than  of  the  Tnore  resistant  enamel. 

I  have  taken  this  up  at  some  length,  because,  while  I  am  not  deal- 
ing in  this  work  with  etiology,  it  becomes  essential  to  be  able  to  decide 
between  an  abraded  and  an  eroded  surface,  because  they  require 
different  modes  of  treatment.     An  abrasion  may  safely  be  filled  with 
gold,   while  to  so  treat  an  erosion  is  often  futile. 
Fig.  142.  These  groovings  in  the  incisive  edges  of  incisors 

then  are  abrasions,  and  should  be  filled  with  gold, 
or  gold  and  platinum,  as  early  as  possible,  when 
filling  is  demanded.  Fig.  142  shows  atypical  case 
in  a  central  incisor.  The  palatal  aspect  of  the  tooth 
is  shown,  because  from  this  view  we  may  best  see 
the  depredation.  It  is  observable  that  the  abrasion 
is  greater  at  the  distal  corner.  This  is  frequently 
the  case,  due  probably  to  the  fact  that  this  corner 
occludes  with  two  teeth,  thus  striking  against  two  sharp  corners  instead 
of  one.  Or  it  may  be  because,  as  we  are  prone  to  pass  the  food  into 
one  side  of  the  mouth  or  the  other,  the  distal  corner  will  be  given 
more  work  than  the  mesial. 

Here  we  find  a  tooth  needing  filling,  but  having  no  cavity.  It  will 
be  requisite  for  the  dentist  to  be  able  to  thoroughly  explain  the  neces- 
sities of  the  case  to  his  patient,  and  he  should  also  command  his  full 
confidence.     The  first  point  to  be  decided  is  whether  or  not  the  in- 


ABRASION. 


M3 


cisors  really  need  to  be  filled.  The  only  object  is  to  save  the  teeth 
from  further  abrasion,  as  decay  is  neither  present  nor  likely  to  occur. 
Where  the  incisors  alone  are  involved,  they  should  be  filled,  la  such 
a  mouth  it  will  be  found  that  in  the  forward  occlusion,  as  when  biting 
bread,  the  posterior  teeth  do  not  touch.  This  is  a  normal  condition, 
and  if  present,  notwithstanding  the  fact  that  the  incisors  are  abraded, 
it  will  indicate  that  the  anterior  teeth  have  not  yet  been  materially 
shortened,  so  that  to  avoid  further  loss  they  themselves  must  be  filled. 
In  a  case  which  has  advanced  further,  when  the  forward  bite  is  essayed, 
the  posterior  teeth  will  usually  be  found  in  contact,  though  this  is  not 
an  invariable  rule.  This  will  show  that  the  anterior  teeth  have  been 
considerably  shortened.  Under  these  circumstances  it  may  not  be 
necessary  to  interfere  in  the  incisive  region  at  all,  for  as  the  teeth  come 
squarely  together  regardless  of  which  bite  is  attempted,  it  follows  that 
if  the  posterior  teeth  be  filled  in  their  masticating  surfaces  further 
abrasion  may  be  retarded  all  around  the  arch.  If  this  be  true,  it  will 
be  unwise  to  disfigure  the  front  of  the  mouth  by  placing  gold  in  the 
incisive  edg-es  of  the  incisors. 


Fig.  143. 


Fig.  144. 


Fig.  145. 


The  preparation  of  such  a  cavity  as  must  be  made  in  a  tooth 
abraded  as  shown  in  Fig,  143  is  as  follows.  With  a  corundum  stone 
lightly  pass  over  the  labial  edge  to  make  it  smooth  ;  then  dress  down 
the  palatal  edge  rather  freely,  designing  to  restore  it  with  a  sufficiency 
of  gold  to  make  a  good  resistant  surface  to  the  action  of  the  oppos- 
ing teeth.  With  a  rose  bur  cut  a  groove,  being  careful  not  to  reach 
the  enamel  in  any  part.  With  bur  or  drill  form  an  extension  or  pit 
at  each  end  of  the  groove  as  shown  by  the  dotted  lines  at  a,  a.  In 
filling,  start  with  pellets  of  gold  foil,  and  complete  with  gold  and 
platinum,  being  extremely  careful  to  thoroughly  unite  and  condense 
■each  piece. 

When  abrasion  has  been  allowed  to  progress  for  years,  we  have 
that  condition  which  has  probably  originated  the  legend  among  cer- 
tain folk  that  their  grandfathers  had  "  double  teeth  all  around."  A 
central  incisor  might  present  as  shown  in  Fig.  144,  the  occluding 
tooth  now  fitting  it  like  a  die,  there  being  little  if  any  concavity.  When 
filling  a  set  of  teeth  thus  destroyed,  I   deem  it  unwise  to  essay  the 


144 


METHODS  OF  FILLING   TEETH. 


opening  of  the  bite  to  any  extensive  degree.  The  patient  is  usually 
old,  and  will  be  happier  if  not  asked  to  adopt  a  new  habit.  In  the 
tooth  figured,  it  is  essential  to  completely  tip  the  edge  with  gold. 
I  should  begin  by  shortening  the  tooth  equal  to  the  amount  of  gold 
which  I  had  decided  should  extend  over  the  edge.  This  would  at 
the  same  time  bring  the  tooth  into  a  more  symmetrical  form,  as 
shown  in  Fig.  145.  The  preparation  of  the  cavity  is  simple,  con- 
sisting of  the  formation  of  a  cup,  and  a  groove  around  to  render  the 
shape  retentive.  There  is  usually  no  difficulty  from  the  pulp,  which 
we  commonly  find  either  devitalized  or  calcified.  For  filling,  gold 
and  platinum  is  preferable  to  gold,  because  more  resistant. 

A  somewhat  similar  form  of  tooth  might  occur  as  a  result  of  frac- 
ture, but  in  that  case  we  should  have  to  consider  the  presence  of  the 
pulp,  which  now  would  not  be  found  calcified.  We  might  make  some 
slight  undercutting,  as  shown  in  Fig.  85,  where  a  failure  by  another 
dentist  was  recorded,  but  it  would  be  wiser  to  also  rely  upon  screws^ 
as  indicated  in  Fig.  96,  where  a  lateral  incisor  was  built  down. 

Fig.  146. 


Possibly  the  most  trying  cases  along  the  incisive  edges  are  those 
which  appear  as  seen  in  Fig.  146,  where  we  have  incisors  in  which  the 
incisive  edge  is  partly  absent  as  a  result  of  fracture,  whilst  what  is  left 
is  thin,  friable,  and  malformed.  Such  teeth  have  been  referred  to 
syphilitic  taint,  to  rickets,  and  to  measles.  Whatever  the  etiology  of 
the  condition  may  be  ultimately  proven  to  be,  in  the  meanwhile  we 
have  to  contend  with  it  as  it  is.  Where  neither  fracture  nor  caries  has 
supervened,  however  unsightly  the  affected  teeth  may  appear,  we  viay 
decide  upon  non-interference.  When,  however,  one  or  more  of  the 
teeth  are  found  as  in  Fig.  146,  we  are  compelled  to  do  something. 
To  attempt  a  gold  filling  in  the  break  only  would  be  folly,  for  the 
adjacent  parts  do  not  offer  a  reasonable  hope  of  maintaining  their 
integrity.  Neither  could  we  place  the  gold  so  that  it  would  have  a 
fairly  commendable  appearance.  Most  often  the  serious  disfigure- 
ment is  chiefly  confined  to  the  four  incisors,  extending  higher  on  the 
centrals  than  on  the  laterals.  Rarely  the  incisive  ends  may  be  ground 
off  similarly  to  the  method  indicated  in  Figs.  121  and  122.  Suppose 
that  we  decide  against  shortening  the  teeth,  and  determine  upon  fill- 


ABRASION. 


145 


ing,  the  procedure  would  be  as  follows  :  Grind  off  all  the  ragged  ends 
of  the  four  incisors,  and  then  prepare  each  in  the  form  of  a  groove, 
in  which  place  screws,  three  in  each  central  and  two  in  each  lateral 
incisor,  as  shown  in  Fig.  147.  The  fillings  should  be  made  with  gold 
and  platinum,  and  the  contour  restored  sufficiently  to  render  the 
length  of  the  teeth  adequate,  though  we  need  not  always  build  to 
original  lines.  The  result  is  shown  in  Fig.  148,  where  we  note  that 
the  border-line  on  all  four  teeth  has  been  made  uniform.     Slight  im- 


FiG.  147. 


t  .J 


perfections  still  appear  in  the  centrals.  These  are  merely  pits  which 
are  shallow,  and  it  would  be  unwise  to  remove  enough  of  the  teeth 
to  eradicate  them  when  they  are  so  high.  Some  would  argue  in 
favor  of  tipping  these  teeth  with  porcelain,  while  others  might  advo- 
cate cutting  off  the  crowns  and  replacing  them  with  artificial  substi- 
tutes. I  am  not  discussing  here  the  relative  values  of  such  methods, 
but  must  be  understood  simply  as  describing  how  to  fill  these  teeth, 
when  such  procedure  is  deemed  best  by  the  operator. 

The  incisive  edge  of  the  cuspid  is  different  from  that  of  incisors, 

Fig.  148. 


and  may  be  considered  unique,  since  it  also  varies  materially  from  the 
cusp  of  the  bicuspids,  in  being  more  readily  cleansed  of  food  because 
of  its  being  a  single  instead  of  a  double  cusp.  Nevertheless,  genuine 
caries  will  occur  with  more  frequency  along  the  edge  of  this  tooth 
than  in  the  incisors  or  the  ends  of  the  bicuspid  cusps.-  This  will  be 
seen  with  greater  frequency  in  mouths  which  show  such  incisors  as 
I  have  just  been  discussing,  and  the  probability  is  that  whilst  the 
cuspids  escape  the  extensive  malformation,  nevertheless  there  oftea 


146 


METHODS  OF  FILLING   TEETH. 


occur  imperfections  in  the  enamel  which,  being  deep  pits,  readily  serve 
as  an  initial  point  for  true  caries.  In  this  class  of  teeth  we  may  find 
such  cavities  as  is  shown  in  Fig.  149,  where  we  see  that  the  decay  has 
destroyed  the  edge  to  one  side  of  the  median  line  of  the  tooth.  This 
will  happen  oftener  than  the  cavity  shown  in  Fig.  150,  where  the  ac- 
tual tip  or  point  is  absent.  The  preparation  of  either  of  these  cavities 
is  simple,  and  is  indicated  by  the  dotted  lines  in  the  illustrations.  It 
consists  of  removal  of  all  decay,  which  will  usually  leave  a  cup  shape 
favorable  for  our  purpose  anyway,  but  which  maybe  strengthened  by 
slight  extensions  in  opposite  directions,  rendering  the  filling,  when 
placed,  larger  within  than  at  the  orifice. 

In  Fig.  151  we  see  a  cavity  which  would  result  were  the  last  one 
neglected.  Its  preparation  and  filling  is  similar  to  that  of  the  smaller 
cavity,  except  that  we  must  get  stronger  anchorage,  since  a  more  ex- 
tensive contour  is  now  needed,  and,  moreover,  having  approached  the 


Fig.  149. 


Fig.  150. 


Fig.  151. 


pulp,  great  care  is  requisite  lest  that  organ  be  injured.  The  main 
idea  after  the  removal  of  all  decay,  is  to  avoid  taking  away  any  of  the 
dentine  covering  the  end  of  the  pulp,  which  we  know  is  near.  Indeed, 
it  is  a  general  fact  to  be  observed  in  the  preparation  of  all  cavities 
by  the  methods  which  I  advocate,  that  a  well-marked  hill  of  dentine 
appears  within  the  cavity  and  over  the  pulp,  which  principle  has  been 
explained  diagrammatically  in  Figs.  3,  4,  5,  and  6.  Avoiding,  then, 
the  central  point  of  the  cuspid  cavity,  deep  extensions  are  to  be  made 
at  each  side,  slanting  away  from  the  pulp  and  lying  parallel  to  the 
mesial  and  distal  sides  of  the  tooth.  Where  the  cuspid  is  quite  thick 
through,  an  advantage  will  be  gained  by  forming  a  deep  groove  con- 
necting these  lateral  extensions  along  the  palatal  part  of  the  cavity. 
A  groove  of  some  depth  must  be  made  in  any  event,  for  it  must  be 
remembered  that  in  mastication  the  forces  exerted  will  operate  to 
throw  the  filling  outward  toward  the  labial  side.  This  undercut  along 
the  palatal  side  therefore  will  be  a  valuable  restraint,  provided  that  it 
is  not  made  at  the  expense  of  weakening  the  wall,  a  circumstance 
which  should  prevent  undercutting  in  any  position.  All  of  these  cavi- 
ties in  cuspids  I  prefer  to  fill  with  gold.      I  like  its  appearance  better 


BICUSPIDS.  147 

than  the  gold  and  platinum,  and  in  the  cuspid,  where  we  have  a  point 
and  two  slanting  planes,  the  force  of  mastication  is  much  less  injurious. 
A  good  gold  filling  in  the  edge  of  a  cuspid  will  do  faithful  service  in 
comparison  with  gold  and  platinum  in  the  incisors  of  the  same  mouth. 

Where  the  end  of  a  cuspid  has  been  worn  off  square  by  abrasion, 
the  one  point  to  be  specially  noted  here  is  that  the  tooth  is  not  to  be 
restored  to  its  original  shape  by  reproducing  the  point.  Occasion- 
ally it  may  be  necessary  to  produce  a  general  effect  by  forming  slightly 
slanting  planes  rather  than  to  make  a  perfectly  square  end,  but  ordin- 
arily it  will  be  best  to  simply  fill  the  concavity  flush  with  the  highest 
point  of  enamel  remaining,  extending  the  material  over  the  enamel  as  a 
protection.  Here,  of  course,  as  with  the  abraded  incisors,  we  must 
use  gold  and  platinum,  for  the  teeth  are  now  occluding  squarely  end 
to  end  most  of  the  time,  if  not  always. 

I  pass  now  to  bicuspids,  and  in  doing  so  I  cross  that  line  which  by 
some  has  been  erected  as  a  point  beyond  which  it  is  permissible  to  fill 
teeth  Avith  gold  or  with  amalgam,  according  to  the  pocket-book  of  the 
patient.     I  have  already  said  that  a  money  consideration  is  an  un- 
scientific standpoint  from  which  to  choose  a  filling-material.     Yet  I 
must  recognize  this  line,  or  at  least  the  territory  on  one  side  of  it. 
Nothing  would  tempt  me  to  fill  any  incisor  or  cuspid  with  amalgam, 
except  in  rare  cases  where  the  cavity  extended  under  the  gum  in  such 
a  way  that  my  judgment  should  indicate  that  gold  would  fail  or  oc- 
casionally in  the  presence  of  persistent  erosion.      Consequently  in 
crossinglthe  line  I  must  admit  that  I  enter  the  domain  of  amalgam. 
Yet  I  cannot  remember  to  have  used  it  to  any  extent  in  the  mesial 
surface  of  a  first  biscupld. 

The  minute  crown  cavities  found  at  the  extremities  of  the  sulci  in 
bicuspids  are  extremely  important,  especially  when  found  in  the  mouths 
of  young  persons.  Nothing  is  easier  than  to  fill  these,  yet  it  is  an 
uncommon  thing  to  see  them  filled  properly.  What  is  the  reason  of 
this  ?  It  will  be  profitable  to  discuss  it  a  moment.  A  well-dressed 
young  miss  of  fourteen  to  sixteen,  let  us  say,  is  brought  into  the  office 
for  an  examination.  The  mirror  alone  shows  large  cavities  in  all  four 
of  the  sixth-year  molars,  for  the  parents,  though  well  bred,  stupidly 
' '  took  them  for  temporary  teeth. ' '  Smaller  cavities  of  a  similar  na- 
ture are  seen  in  the  twelfth-year  molars.  Frequently  the  operator 
stops  his  examination  at  this  point,  because  he  has  found  enough  to 
begin  with.  He  tells  the  parent  that  the  child  has  been  brought  in 
' '  in  the  nick  of  time,  for  in  a  few  weeks  the  pulps  would  probably  have 
been  exposed  in  one  or  two  teeth."  He  therefore  chooses  the  worst 
and  makes  a  start.  Perhaps,  after  all,  a  pulp  is  exposed,  which  means 
destruction  and  all  the  trials  and  tribulations  which  follow.  Event- 
ually a  superficial  glance  is  made  at  the  other  teeth,  and  if  an  excava- 


148  METHODS  OF  FILLING   TEETH. 

tor  catches  in  a  bicuspid,  the  parent  is  admonished  to  bring  her  in 
again  in  a  few  months.  Now  such  work  on  the  part  of  the  dentist, 
though  thoroughly  conscientious,  is  not  well  directed.  The  bicuspids 
have  been  neglected,  and  are  sure  to  suffer  from  such  a  course  of  treat- 
ment. In  my  opinion,  the  proper  way  to  examine  a  young  mouth  is 
to  begin  with  a  very  fine-pointed  explorer  and  examine  closely  each 
end  of  each  sulcus,  searching  for  a  place,  however  tiny,  where  the 
instrument  will  penetrate  to  the  dentine.  I  chose  a  "well-dressed" 
miss,  for  the  reason  that  in  such  a  mouth  we  would  probably  find 
clean  teeth,  and  invisible  decay  as  a  consequence.  If  the  explorer 
discovers  a  cavity,  however  small,  that  tooth  must  be  filled  first. 
What  about  those  gaping  cavities  in  the  molars  ?  Let  them  wait,  I 
say.  They  have  been  waiting  for  months,  and  a  day  or  two  more 
will  not  make  much  difference,  whilst  to  begin  with  them,  as  I  have 
shown,  usually  leaves  the  bicuspids  unfilled.  The  bicuspid  with  its 
small  cavity,  when  we  consider  its  immense  value  in  mastication,  its 
ready  salvation  if  immediately  cared  for,  and  the  extreme  difficulties 

Fig.  152.  Fig.  153. 


which  it  may  bring  to  us  later  if  not  saved  at  the  outset,  certainly  must 
be  counted  as  worthy  of  our  first  attention.  Of  course  there  is  no 
need  to  neglect  the  molars  to  their  detriment,  either.  If  the  work 
cannot  be  done  coincidently,  the  decay  may  be  removed  from  the 
molars  and  temporary  fillings  inserted,  whilst  we  give  our  first  atten- 
tion to  the  bicuspids. 

Whether  the  crown  of  the  bicuspid  shows  one  or  two  cavities,  is 
immaterial.  In  either  event  the  sulcus  must  be  cut  out  entirely  across 
from  end  to  end.  This  I  have  stated  before,  and  I  said  that  there 
may  be  a  i^-w  exceptions.  These  will  occur  more  often  in  the  lower 
jaw,  and  are  confined  to  that  class  of  teeth  in  which  there  is  no  well- 
marked  sulcus,  but  simply  a  pit  at  each  side,  the  cusps  being  fused 
along  the  median  line.  In  all  other  cases,  extend  the  cavity  to  the 
full  length  of  the  sulcus,  and,  moreover,  it  must  not  be  cut  out  with 
a  tiny  drill,  and  filled  afterward  so  that  a  thread-like  streak  of  gold 
is  all  that  shows.  Fig.  152  is  diagrammatic,  and  is  introduced  to 
show  the  fallacy  of  this  procedure.  It  gives  a  section  through  a 
bicuspid,  and  shows  the  tiny  filling  lying  at  the  bottom  of  the  sulcus. 
To  so  fill  a  bicuspid  gives  the  operator  a  chance  to  exhibit  his  skill, 
for  it  is  more  difficult  to  place  a  solid  filling  in  such  a  place  than 


BICUSPIDS.  149 

where  the  cavity  is  enlarged.  Early  in  my  career  it  was  my  pride  to 
make  these  thread-like  fillings  in  bicuspids,  and  in  molars  as  well, 
following  all  the  windings  of  the  sulci.  But  it  is  an  error,  for  it 
leaves  the  sulcus  practically  existent,  and  in  it  food  will  lodge,  so  that 
caries  will  probably  recur,  the  gold  dropping  out.  Fig.  153  shows 
an  enlargement  of  the  cavity,  the  filling  now  extending  up  and  filling 
the  sulcus,  so  that  we  have  left  the  cusps  sufficiently  well  marked  for 
masticatory  uses,  whilst  we  have  obliterated  the  dangerous  lodging- 
place  for  food  and  other  material.  In  order  to  be  sure  to  have  suffi- 
cient gold  in  this  sulcus,  it  is  well  to  overbuild,  so  that  after  doing  so 
the  gold  must  be  cut  away  to  permit  normal  occlusion.  By  this  means 
we  have  as  much  gold  as  will  be  tolerated,  and  the  tooth  is  safer  for 
it.  This  rule  holds  with  all  crown  cavities.  The  preparation  of  the 
cavity  to  make  it  retentive  is  simple.  With  a  reversed-cone  bur  dip 
into  the  cavity  at  one  end,  and  cut  until  it  emerges  at  the  other. 
This  will  form  a  slight  undercut,  which  may  be  deepened  by  following 

Fig.  154.  Fig.  155.  Fig.  156. 


the  same  course  with  a  wheel  bur.  Before  filling,  a  fine  hatchet 
excavator  should  be  introduced  at  each  end  to  make  sure  that  all 
caries  is  removed.  The  depth  which  will  often  be  reached  before  this 
is  done  will  astonish  those  whose  habit  has  been  to  neglect  bicuspids 
till  the  cavities  become  visible  to  the  eye.  For  these  cavities  gold  is 
the  only  proper  material,  and  it  can  be  placed  so  rapidly  and  readily 
that  there  is  no  excuse  for  the  use  of  amalgam. 

Leaving  Fig.  153,  no  special  directions  are  needed  relating  to 
simple  crown  cavities  till  we  come  to  such  as  is  shown  in  Fig.  154,  a 
sectional  view  of  which  is  given  in  Fig.  155.  The  entrance  to  this  is 
along  the  full  extent  of  the  sulcus.  If  prepared  with  engine-burs 
alone,  it  would  be  more  than  probable  that  much  caries  would  be  left 
unremoved.  Generally  speaking,  it  should  be  remembered  that  the 
dentine,  as  a  whole,  assumes  about  the  same  form  as  the  entire  tooth. 
From  this  it  follows  that  as  the  enamel  over  the  cusps  forms  cones, 
underlying  this  enamel  in  a  healthy  tooth  we  would  find  cones  of 
dentine.  Caries  finds  its  way  through  the  weakest  part  of  the 
enamel,  which  is  along  the  sulcus,  but  once  it  reaches  the  dentine, 
further  loss  of  the  enamel  is  rather  by  a  destruction  of  the  dentine, 


ISO 


METHODS  OF  FILLING   TEETH. 


so  that  the  enamel  thus  undermined  fractures  under  the  force  of  mas- 
tication and  caves  in.  Frequently,  however,  the  teeth  come  to  us 
thoroughly  undermined,  but  with  the  enamel  apparently  intact  except 
at  the  small  orifice  along  the  sulcus.  Thus  the  dentine  just  under  the 
cusps,  though  decayed,  might  be  left  in  the  cavity  unless  special  care 
be  taken  to  remove  it.  A  shepherd' s-crook  excavator  might  accom- 
plish this,  but  the  result  is  scarcely  desirable,  as  even  where  all  the 
carious  dentine  is  successfully  taken  away  the  cusps,  unsupported  by 
dentine,  are  likely  to  crush  under  mastication  later  on.  I  therefore 
advise  the  free  use  of  the  chisel  to  thoroughly  expose  the  cavity,  and 
reach  strong  borders.  With  a  sharp  chisel  placed  at  the  points  a,  a, 
gentle  taps  of  a  mallet  will  remove  the  overhanging  enamel  readily 
and  painlessly.  Painlessly,  because  the  enamel  is  taken  off  in  the 
line  of  fracture,  so  that  the  patient  finds  no  concussion  from  the  mallet- 
blow.  The  final  arrangement  of  the  cavity  is  best  shown  by  a 
diagrammatic  illustration,  as  seen  in  Fig.  156.  This  may  be  con- 
sidered a  section  through  the  tooth,  and  shows  first  that  the  cusps 
have  been  cut  away  so  that  the  filling  when  inserted  covers  them  suffi- 
ciently to  afford  protection,  and  secondly  we  see  that  in  finishing  the 
filling  no  attempt  has  been  made  to  exactly  reproduce  the  form  of 
the  masticating  surface.  The  filling  is  merely  made  to  resemble  a 
bicuspid  crown  in  a  general  way,  being  left  smooth  and  gently  curved, 
so  that  it  is  readily  cleansed. 

As  to  selection  of  filling-material,  I  should  certainly  lean  toward 
gold,  unless  contraindicated  by  circumstances  peculiar  to  an  individual 
case.  To  pack  the  gold  I  should  resort  to  the  method  of  using 
oxyphosphate  in  the  bottom  of  the  cavity,  pressing  in  the  first  pellets 
whilst  the  cement  was  still  plastic.  This  I  shall  describe  more  particu- 
larly when  I  come  to  molars.  Where  a  dentist  prefers  to  use  amalgam, 
it  will  be  seen  that  no  alteration  of  the  cavity  will  be  required.  Neither 
need  I  give  any  special  directions  for  placing  the  amalgam,  the  cavity 
being  very  simple.  I  should  insist  on  the  return  of  the  patient  for  sub- 
sequent polishing. 

In  Fig.  157  we  have  a  bicuspid  from  which  one  cusp  has  been  lost. 
When  this  is  the  palatal  cusp  it  would  be  as  well  not  to  attempt  a  full 
restoration,  but  to  be  satisfied  with  an  approximate  contour,  so  that 
the  tooth  when  filled  may  appear  as  shown  in  Fig.  158.  This  is  dia- 
grammatic, giving  a  section  through  the  filled  tooth,  and  indicating 
the  outer  form  attained,  as  well  as  the  relation  of  the  gold  to  the  cavity 
itself.  'Where,  however,  the  cusp  which  is  absent  is  the  labial,  it  will 
not  answer  to  so  proceed,  for  by  not  reproducing  the  full  cusp  we  leave 
an  ill-shaped  tooth  to  attract  attention,  especially  as  the  occlusion 
would  not  be  reached.  Of  course  the  occlusion  would  not  be  reached 
in  the  first  case  either,  but  being  out  of  sight  this  would  be  of  no  im- 


BICUSPIDS. 


151 


portance.  Occasionally  we  may  be  able  to  anchor  a  filling  of  this 
nature  so  securely  that  we  may  be  satisfied  to  risk  a  fiall  contour. 
Where  it  can  be  done,  the  procedure  is  as  follows.  The  removal  of 
all  decay  would  give  us  a  general  concavity  of  somewhat  irregular 
shape. 

Begin  by  forming  deep  grooves  along  each  approximal  wall,  as 
indicated  at  a,  a,  in  Fig.  159.  Unite  these  with  a  groove  around  the 
labial  wall,  as  at  d.  This  will  give  a  groove  of  horse-shoe  shape. 
Make  extensions  at  the  labio-approximal  angle  on  each  side,  as  deep  as 
safety  will  permit.  Note  that  the  groove  is  a  horse-shoe,  the  circle 
not  being  completed.  To  do  so  would  mean  to  extend  the  groove 
along  the  base  of  the  remaining  cusp,  which  would  greatly  weaken  it, 
without  affording  adequate  compensation  for  the  risk  involved.  In 
fact,  except  in  rare  cases,  where  the  standing  cusp  is  found  unusually 
strong,  do  not  attempt  any  undercutting  or  grooving  at  this  point  at 

Fig.  157.  Fig.  158.  Fig.  159.  Fig.  160. 


all.  A  general  concavity  of  the  whole  inner  surface  of  the  cusp,  as 
at  c,  will  be  sufficient  to  act  with  the  opposing  groove,  and  retain  the 
full  contour.  Or  if  not,  then  one  or  two  gold  screws  should  be  em- 
ployed. A  first  glance  at  Fig.  158  might  leave  the  impression  that  the 
fining  would  not  remain  in  place  because  of  the  fact  that  only  a  single 
retainer,  d,  is  shown.  It  must  be  remembered,'  however,  that  this,  which 
here  is  at  the  palatal  side  of  the  tooth,  is  analogous  to  the  groove  at  ^ 
in  Fig.  159,  where  it  occurs  at  the  labial.  The  section  does  not  indi- 
cate the  latei'al  grooves,  which  would  occur  in  such  a  case  as  Fig.  15S, 
just  as  has  been  described  in  Fig.  159.  As  to  filling-materials,  in 
such  a  case  as  Fig.  159  it  seems  to  me  that  we  must  use  gold,  as  the 
contoured  cusp  is  exposed  to  view.  In  Fig.  15S,  where  the  whole 
filling  will  be  unseen,  amalgam  may  be  used  under  some  circumstances, 
as  for  example  in  the  mouth  of  one  for  whom  a  lengthy  operation 
would  be  a  risk,  because  of  shock.  Ordinarily  I  should  use  gold  in 
either  case.  I  should  begin  at  the  end  of  the  distal  groove,  and,  using 
pellets,  build  around  till  the  groove  itself  was  solidly  packed.  Then  I 
should  build  across,  connecting  the  two  arms  of  the  horse-shoe  groove, 
so  covering  the  floor  of  the  cavity.  Keeping  my  gold  with  a  flat  sur- 
face, I  should  build  up  till  on  a  level  with  the  border  where  the  cusp 
was  absent.     Next  work   toward   the  remaining  cusp,  and  cover  it 


152  METHODS  OF  FILLING  TEETH. 

completely  with  a  thin  layer  of  gold.  This  is  an  important  point, 
and  that  I  may  be  better  understood  I  will  resort  to  a  diagram.  Fig. 
1 60  shows  the  tooth  in  section,  filled  to  a  level  with  the  labial  wall  b 
(supposing  that  we  are  dealing  with  Fig.  159).  It  is  plain  that  up  to 
this  point  it  has  been  easy  to  keep  the  direction  of  the  plugger  and 
mallet-blow  perpendicular  to  the  long  axis  of  the  tooth,  or  in  line  with 
the  length  of  the  root.  By  this  method  the  blow  receives  the  greatest 
resistance,  so  that  the  gold  is  most  solidly  packed,  while  the  patient 
reports  the  least  pain.  Were  we  to  proceed  thus  to  the  end,  it  would 
be  found  that  we  would  be  constantly  called  upon  to  pay  special  atten- 
tion along  the  standing  wall,  as  for  example  at  the  point  indicated  by 
a  in  the  diagram.  We  should  be  compelled  to  place  every  piece  at 
that  point,  first  building  from  there  outward,  or  else  risk  imperfect 
packing  at  this  point.  In  this  way  we  would  lose  the  horizontal  plane, 
the  surface  of  the  filling  soon  becoming  oblique.  Thus  throughout 
the  rest  of  the  operation  the  mallet-stroke  would  not  be  perpendicular 
to  the  root.  I  advise  immediately  covering  the  wall  as  shown  in  the 
diagram  at  c.  To  do  this  of  course  necessitates  either  hand-pressure, 
or  the  mallet  at  an  oblique  angle.  Even  the  latter,  which  is  preferable, 
would  cause  little  pain,  because  the  wall  would  be  sufficiently  covered 
with  a  few  pieces  of  gold.  With  the  cavity  filled  up  to  the  point 
shown  in  the  diagram,  the  completion  may  be  carried  on  with  com- 
parative rapidity,  because  the  tooth-substance  being  all  covered  we 
have  no  further  anxiety  in  that  direction,  but  may  devote  our  attention 
exclusively  to  shaping  the  contour.  From  this  point  use  heavy  foil, 
No.  30,  or  possibly  60,  cut  in  square  pieces,  and  pack  from  the  cusp 
b  toward  the  point  a.  Allow  each  piece  to  overlap  the  cusp  ^,  and 
in  this  manner  the  labial  portion  will  grow  sufficiently  outward,  so 
that  surface  packing  will  not  be  required  when  the  contour  is  formed. 
This  is  a  most  important  point,  for  we  must  have  the  labial  surface 
dense  so  that  we  may  give  it  a  high  polish,  yet  it  is  undesirable  to  be 
compelled  to  pack  gold  on  that  part  of  the  filling  at  the  end  of  the 
operation,  because  the  force  of  the  blow  would  be  at  right  angles 
to  the  tooth,  which  by  this  time  may  have  become  so  tender  that 
this  would  be  exceedingly  painful.  It  can  be  readily  avoided  if  the 
caution  to  build  over  the  edge  with  every  piece  be  heeded. 

There  may  be  some  who  will  argue  that  I  am  in  error  when  I  state 
that  no  special  retaining-point  or  undercut  should  be  made  along  the 
remaining  cusp.  Yet  if  so,  what  are  we  to  do  where  both  cusps  are 
lost,  as  in  Fig.  161?  In  such  a  case  the  same  method  which  I 
described  in  connection  with  Fig.  159  may  be  followed.  Here,  how- 
ever, we  do  not  make  the  groove  a  horse-shoe,  but  complete  the 
circle,  for  we  have  no  standing  wall  in  danger  of  being  undermined. 
Fig.  161  shows  the  cavity  prepared  for  filling,  the  groove  being  seen 


MOLARS. 


153 


Fig.  161. 


Fig.  162. 


dt   a.      In    Fig.    159    I    advised    retaining   extensions   at  the   labio- 
approximal  angles.     In  this  case  they  are  to  be  made  at  the  palato- 
approximal  angles  also.     Thus  we  would   have  a   filling  which,    if 
removed  from  the  tooth  for  examina- 
tion (the  tooth  having  been  extracted 
and  cracked  open),  would  appear  to 
have  four  legs  to  stand  upon,  which 
legs  would  flare  outwardly  to  a  slight 
extent.      Fig.    162    gives  a   section 
through  the  tooth  and  filling,  where 
the  retentive  arrangement  is  readily 

seen.  Where  the  depredation  extends  beyond  this,  so  that  good 
retaining-grooves  and  extensions  could  not  be  made  without  endan- 
gering the  pulp,  it  would  be  better  to  depend  upon  four  screws,  which 
should  be  thoroughly  well  anchored  when  asked  to  hold  so  great  a 
contour. 

In  molars  we  find  a  greater  variety  of  crown  cavities.  As  in 
bicuspids,  there  is  a  class  which  should  receive  our  immediate  atten- 
tion. I  said  that  with  children  I  usually  begin  by  searching  for  and 
filling  the  cavities  in  the  sulci  of  bicuspids.  This  done,  I  next  exam- 
ine the  crowns  of  the  superior  sixth-year  molars.  In  the  pit  at 
the  bottom  of  the  anterior  sulcus  we  are  most  likely  to  find  at  least  a 
small  cavity.  Call  it  a  cavity,  and  fill  it  with  gold,  if  the  point  of  a 
fine  explorer  can  be  made  to  penetrate  so  that  there  will  be  some 
difficulty  in  removing  it.  When  caries  has  but  begun,  there  is  no 
trouble  to  fill  with  gold,  for  the  dam  is  not  a  requisite,  though  always 
an  advantage  if  it  can  be  used  without  serious  objection.  I  seldom 
resort  to  it  with  these  teeth,  because  they  can  be  filled  so  quickly  that 
it  is  better  to  depend  upon  the  napkin  than  to  risk  too  much  annoy- 
ance to  a  young  patient.  Usually  a  rose  bur  will  sufficiently  shape 
the  cavity,  cleansing  it  and  making  it  retentive  at  the  same  time. 
Nevertheless,  before  filling,  it  is  safer  to  examine  with  an  excavator, 
lest  some  white  caries  be  left.  The  cavity  all  ready,  fold  a  large 
napkin  once,  and  introduce  the  doubled  edge  into  the  mouth  and 
back  behind  the  first  molar,  where  it  is  held  in  place  with  a  mouth- 
mirror,  which  at  the  same  time  reflects  light  into  the  cavity.  Should 
there  be  danger  from  the  saliva  flowing  from  the  duct  of  Steno,  a  roll 
of  bibulous  paper  placed  between  the  gums  and  cheek  will  suffice  to 
dam  it  off.  Dry  the  cavity  thoroughly  with  hot  air,  and  select  for 
the  first  pellet  one  which  will  wedge  in  the  cavity.  Better  still,  use 
crystal.  Use  a  shepherd's-crook  plugger  if  working  by  the  reflection 
in  the  mirror,  or  a  slightly- bent  bayonet  if  the  patient  is  tipped  back 
so  that  the  cavity  can  be  easily  seen.  Depend  upon  hand-pressure 
to  start  the  filling,  but  as  soon  as  the  floor  is  covered  and  the  gold 


154 


METHODS  OF  FILLING   TEETH. 


packed  is  immovable,  resort  to  the  mallet.  Here  the  engine- mallet 
or  the  electric  is  most  convenient,  because  one  hand  is  engaged  with 
the  mirror.  In  such  small  cavities  pellets  will  be  more  convenient 
than  heavy  foil,  but  the  latter  should  be  used  at  the  last.  Fill  with 
pellets  up  to  the  level  with  the  actual  borders  of  the  cavity,  and  com- 
plete with  heavy  foil,  building  up  so  as  to  lessen  the  depth  of  the 
sulcus. 

Next,  attention  should  be  given  to  the  posterior  sulcus.  Here  we 
often  find  a  cavity  which  will  be  much  more  trying,  for  which  reason 
the  rubber  is  more  necessary  than  in  the  last  case.  In  this  place  the 
decay  often  extends,  though  perhaps  merely  as  a  line  of  discolora- 
tion, into  the  palatal  groove.  When  this  occurs,  or  in  fact  in  all 
cases  except  where  the  groove  is  scarcely  defined,  the  cavity  should 
be  extended  into  it,  as  is  Well  shown  in  Fig.  i8.  It  is  this  extension 
which  will  often  try  the  patience  of  the  operator,  especially  should  he 
be  compelled  to  trust  to  the  mirror  for  a  view  of  his  work.  After 
many  and  varied  experiences,  I  have  decided  upon  the  following 
method  as  being  the  most  feasible,  and  applicable  to  the  greatest 
number  of  cases  :  After  fully  extending  the  cavity  to  the  extreme  end 
of  the  palatal  groove,  with  a  sharp  spear-drill  make  a  deep  pit  at  this 
point  obliquely,  being  careful,  however,  not  to  wound  the 'pulp. 
Next  enlarge  this  pit  with  a  rose  bur,  after  which  bring  the  bur 
forward  toward  the  crown  cavity  proper,  forming  an  undercut  along 
the  sides  of  the  palatal  extension.  Now  exchange  for  a  wheel  bur, 
and  pass  it  the  full  length  of  the  crown  cavity,  forming  an  undercut 
along  each  side  and  at  the  buccal  end.  A  point  of  interest  is  worthy 
of  note  here.  The  caries  which  decided  the  operator  to  fill  this 
cavity  most  probably  was  noticed  at  this  buccal  end  of  the  sulcus, 
and  is  usually  found  burrowing  toward  the  pulp  rather  than  toward 
the  distal  aspect  of  the  tooth.  Thus  it  is  essential,  after  using  these 
engine  instruments,  to  explore  for  caries  at  this  buccal  end  of  the 
cavity.  In  the  majority  of  instances  it  will  be  necessary  to  remove 
decay,  and  pain,  if  experienced  at  all,  will  be  felt  at  this  time.  Thus 
it  is  a  valuable  axiom,  that  in  all  distal  or  inaccessible  crown  cavities 
the  mesial  side  of  the  cavity  should  invariably  be  explored  with  a 
shepherd  s-crook  hand-excavator,  or  other  shape  suitable  for  reaching 
this  unseen  part  of  the  tooth. 

The  cavity  prepared,  the  filling  should  be  with  gold,  and  is  to  be 
started  with  crystal  in  the  pit  made  at  the  end  of  the  palatal  extension. 
All  of  this  extension  may  be  partly  filled  until  the  gold  is  built  well 
over  into  the  crown  portion.  It  may  then  be  continued  with  pellets 
and  the  mallet  until  two-thirds  completed,  when  heavy  foil  should  be 
used  in  pieces  that  are  narrow,  and  long  enough  to  extend  from  the 
buccal  to  the  palatal  end  of  the  cavity.     By  thus  beginning  at  the 


MOLARS. 


155 


palatal  end,  passing  toward  and  into  the  crown,  finally  returning-  to- 
ward the  starting-point,  the  cavity  may  be  rapidly  and  easily  filled. 
To  begin  in  the  crown,  however,  and  build  over  into  the  palatal  ex- 
tension, will  often  be  found  most  tiresome  and  perplexing. 

I  have  elsewhere  designated  these  two  cavities  as  an  exception  to 
the  general  rule  of  opening  up  sulci  from  end  to  end.  Where  con- 
siderable caries  is  present,  and  the  removal  thereof  discloses  the  fact 
that  the  two  cavities  are  united  below  the  enamel  by  a  narrow  passage, 
I  think  it  best  to  open  up  the  two  into  a  single  cavity,  which  would 
then  appear  as  shown  in  Fig.  163.  Here  it  is  to  be  observed  that  the 
two  cavities  are  connected  only  by  a  narrow  passage.  This  should 
only  be  done  where  the  enamel  at  a,  a  is  well  supported  by  strong  den- 
tine beneath.  Where  the  dentine  is  carious  or  absent,  they  should  be 
cut  away  freely  till  a  strong  wall  is  reached.  This  cavity  will  ordi- 
narily be  easily  filled  with  either  gold  or  amalgam,  the  former,  of 
course,  to  be  preferred,  unless  contraindicated  by  circumstances.    No 


Fig.  163. 


Fig.  164. 


Fig. 165. 


special  arrangement  is  necessary  to  assure  retention,  for  each  cavity 
usually  presenting  of  general  retentive  shape,  the  two  when  united 
form  the  strongest  cavity  that  could  be  designed. 

In  connection  with  a  cavity  of  about  the  magnitude  of  that  prepared 
in  the  last  case,  we  will  sometimes  find  one  cusp  so  undermined  by 
decay,  or  so  imperfectly  calcified,  that  it  must  be  removed  in  order  to 
reach  strong  walls.  A  point  of  special  interest  here  is  the  palatal 
groove.  Even  supposing  that  it  should  be  non-carious,  it  is  essential 
that  at  least  a  slight  extension  of  the  cavity  should  be  made  in  that 
direction.  This  will  give  us  a  cavity  shaped  as  seen  in  Fig.  164,  the 
antero-palatal  cusp  being  absent.  From  this  it  is  at  once  apparent 
that  a  point  of  weakness  occurs  at  a,  where  we  find  that  all  that  is  left 
of  the  cusp  is  frail.  It  is  therefore  obligatory  to  remove  it,  so  that 
the  cavity  ready  for  filling  would  appear  as  in  Fig.  165.  For  the  re- 
tention of  the  filling,  a  deep  groove  should  be  formed  along  the 
approximal  border  and  around  the  palatal  portion  as  far  as  the  palatal 
groove,  as  indicated  at  a,  a.  At  the  palatal  angle  b,  a  depression  is  to 
be  made  as  deep  as  possible  without  danger  to  the  pulp.  Along  the 
base  of  the  standing  walls  slight  undercutting  maybe  resorted  to,  but 


156  METHODS  OF  FILLING   TEETH. 

care  should  be  taken  not  to  undermine  and  weaken  what  is  to  be  the 
strongest  support.  This  caution  especially  applies  to  the  antero- 
buccal  cusp,  which  is  in  danger  of  subsequent  fracture.  The  case  de- 
scribed being  one  in  which  the  depredation  is  supposed  to  involve  the 
approximal  portion  only  very  slightly,  it  is  plain  that  the  dam  could 
be  placed  save  in  exceptionally  short,  or  abnormally  conical  teeth. 
Therefore  I  should  choose  gold  as  a  filling- material.  I  should  start 
the  filling  at  the  palatal  angle  in  the  deep  dip  formed  at  that  point, 
build  backward  to  the  palatal  groove,  thence  over  the  floor  of  the 
cavity  and  along  the  walls,  and  so  around  and  back  to  my  starting- 
place.  All  the  exposed  portion  of  dentine  being  thus  covered,  and 
all  borders  perfected,  the  contour  could  be  rapidly  completed  by  using 
heavy  foil  and  fairly  large  instruments  with  the  mechanical  mallet.  A 
word  as  to  the  contour  here.  As  it  is  not  to  show,  there  is  no  special 
object  in  building  the  cusp  up  to  the  full  original  height,  it  being  re- 
membered that  the  more  gold  the  weaker  the  contour.  Were  this  the 
buccal  cusp  it  would  be  more  essential  to  fully  restore  it,  since  it  would 
be  exposed  to  view.  But  in  no  case  need  the  exact  lines  of  the 
original  be  reproduced.  An  approximate  contour  will  be  sufficiently 
serviceable,  and  will  prove  more  durable  than  where  deep  depressions 
are  made  in  simulation  of  the  normal  sulci. 

Where  two  cusps  are  absent,  if  they  be  the  anterior  ones,  we  must 

observe  the  same  caution  at  the  buccal  groove  as  was  advised  at  the 

palatal,  and  remove  weak  enamel  as  far  as  both  of  these  grooves. 

Such  a  cavity  prepared  for  filling  is  seen  in  Fig. 

Fig.  166.  166.     The  retaining  groove  a,  a  now  assumes  a 

^^^F^^^t^'^  half-circle,  whilst  we  have  two  depressions,  one 

I     /w''^m\     /        ^^  each  angle,  b,  b,  and  there  is  a  slight  undercut 

mli^^r'     1/f  along  the  standing  wall  as  before.     The  filling 

I  "   Nw-^-JB/  f  ^^'^^^  gold  is  practically  as  in  the  last  case.     The 

1||,,||||B^^iiii'i/      f         general  arrangement  of  these  cavities  will  be  as 

^^^^^-*-^  described,   regardless  of  which  cusps  are  lost. 

In  some  conditions  it  maybe  found  advisable  to 

resort  to  screws,  whilst  the  method  shown  in  Fig.  102  may  be  adopted 

in  extreme  cases.     As  long  as  the  approximal  surface  is  only  slightly 

encroached  upon,  however,  the  fillings  can  be  sufficiently  anchored 

without  the  screw,  or  holes  cut  through  the  walls,  for  we  could  make 

the  groove  and  retaining  depressions  of  sufficient  depth  and  strength. 

Where  three  cusps  are  absent,  the  groove  is  extended  still  further, 
and  a  third  depression  at  the  third  angle  is  to  be  made.  With  the 
disappearance  of  the  fourth  cusp  we  have  the  groove  a  complete 
circle,  four  retaining  depressions  being  needed,  one  at  each  angle, 
and  the  tooth  is  filled  and  the  filling  retained  exactly  as  described  in 
connection  with  bicuspids,  and  illustrated  by  Figs.  161  and  162. 


OXYPHOSPHATES  IN  COMBINATION  WITH  GOLD. 


'57 


Whilst  I  prefer  gold  for  all  four  of  these  crown  contours,  amalgam 
may  be  used  with  success.  The  dam  should  be  placed,  the  cavity- 
being  shaped  the  same  as  where  gold  is  to  be  depended  upon.  The 
amalgam  is  then  packed  thoroughly  into  all  undercuts  and  retainers, 
being  forced  into  them  with  balls  of  bibulous  paper  as  has  been 
described.  Supposing  that  all  four  cusps  were  to  be  restored,  thus 
choosing  the  filling  of  the  greatest  magnitude,  in  this  class,  the 
amalgam  should  not  be  mixed  too  dry.  There  should  be  sufficient 
plasticity  to  last  during  the  packing  without  danger  of  fracture,  or 
flaking  off".  The  full  contour  would  be  restored,  the  top  of  the  filling 
appearing  convex.  The  next  step  is  to  hasten  the  setting  of  the  mass 
by  the  addition  of  gold  foil,  as  described  in  connection  with  the  use 
of  amalgam.  The  foil  is  cut  or  torn  into  small  pieces,  preferably  as 
thin  as  No.  3  foil,  and  a  single  piece  laid  over  the  amalgam.  This  is 
then  burnished  into  the  filling  with  a  smooth  warm  burnisher,  and 
becomes  incorporated  with  it.  This  is  continued  until  it  is  found  that 
the  amalgam  is  hardening.  Then  the  contour  may  be  perfected  by 
carving  gently  with  a  right-angled  spatulate  burnisher.  The  burnish- 
ing of  gold  is  then  continued,  smaller  ball  burnishers  carrying  the  foil 
into  the  depressions  which  have  been  carved  out,  and  rounding  and 
perfecting  the  lines.  This  is  kept  up  till  the  filling  is  set  enough  to 
be  dismissed  in  safety,  at  which  time  it  will  usually  appear  to  be  a 
gold  filling,  the  final  pieces  of  gold  retaining  their  color.  This,  how- 
ever, is  lost  in  the  subsequent  crystallization,  so  that  when  seen  at  the 
next  sitting  the  usual  amalgam  color  is  presented,  save  perhaps  in 
spots.  A  peculiar  squeaking  sound  as  the  burnisher  passes  over  the 
surface  will  admonish  the  operator  that  the  mass  has  begun  to  harden. 
If  the  filling  after  setting  be  thoroughly  polished,  it  will  appear  very 
handsome,  and  will  prove  a  good  and  durable  piece  of  work. 

I  must  refer  to  the  large  crown  cavities,  where  the  cusps  are  intact, 
but  where  the  cavity  itself  is  so  large  that  further  extension  in  any 
direction,  either  for  starting-point  or  for  retention,  would  so  weaken 
the  wall  as  to  make  subsequent  fracture  a  probability.  It  is  evident 
enough  that  such  a  cavity  will  retain  the  filling  once  we  get  it  in,  but 
how  shall  we  accomplish  this  with  gold  ?  It  is  in  this  class  of  cases 
that  the  oxy phosphate  method  is  found  most  satisfactory.  I  promised 
to  explain  this  in  more  detail,  and  will  do  so  here.  After  the  removal 
of  all  decay,  the  dam  of  course  being  in  place,  mix  oxyphosphate  to 
a  sticky  consistency,  and  place  it  in  the  bottom  of  the  cavity.  Whilst 
still  plastic,  press  into  it  two  or  three  large  pellets  of  gold  foil  loosely 
rolled,  and  without  condensing  let  the  whole  rest  till  th-e  cement  sets 
hard.  We  then  have  such  an  appearance  as  is  shown  by  Fig.  167. 
In  this  illustration,  a  represents  the  oxyphosphate,  which  it  is  observed 
has   been   squeezed  out  over  the  borders,  c,  c,  whilst  b  shows  the 


158 


METHODS  OF  FILLING   TEETH. 


loosely  packed  gold  bulging  out  of  the  cavity.  As  soon  as  the 
cement  is  set,  whilst  waiting  for  which  gold  may  be  prepared  for 
filling  the  tooth,  the  next  step  is  to  condense  the  gold  and  remove 
the  excess  of  cement.  This  done,  the  presentation  would  be  as  in 
Fig.  i68,  a  once  more  showing  the  phosphate,  whilst  b  indicates  the 
gold  condensed  and  cemented  to  the  floor  of  the  cavity.  It  is  to  be 
noted  that  the  unfilled  portion  of  this  cavity  is  still  retentive,  so  that 
whilst  the  gold  is  actually  cemented  to  the  tooth,  no  special  depend- 
ence is  placed  upon  that  for  keeping  the  filling  in  the  cavity.  To 
continue  this  filling  care  must  be  taken  to  cover  the  phosphate  at  the 
exposed  points  c,  c,  so  that  no  particles  may  be  chipped  ofl"  to  inter- 
fere with  thorough  cohesion.  This  is  best  done  by  carefully  laying 
in  pieces  of  heavy  foil,  uniting  them  at  the  center  with  the  gold 
already  in  place,  and  extending  them  over  the  phosphate  till  the 
entire  floor  is  presented  as  a  gold  surface,  when  the  completion  of  the 
filling  is  comparatively  easy.  Where  amalgam  is  to  be  used,  the 
procedure  is  similar,  with  a  noteworthy  exception.     The  appearance 


after  removal  of  the  excess  of  phosphate  would  be  as  seen  in  Fig. 
169,  a  as  before  representing  the  phosphate,  which  here  extends 
higher  up  the  sides  of  the  walls,  whilst  b  is  now  the  amalgam.  The 
completion  would  leave  but  a  small  portion  of  the  amalgam  in  actual 
contact  with  the  dentine.  Amalgam  fillings  thus  inserted  do  not  dis- 
color the  teeth. 

In  the  preparation  of  a  crown  cavity  in  a  molar,  especially  in  the 
lower  jaw,  it  will  occasionally  occur  that  in  following  the  direction 
taken  by  the  caries,  we  discover  that  it  has  eaten  its  way  through  to 
the  approximal  surface.  I  have  elsewhere  said  that  where  a  cavity 
occurs  in  the  crown,  and  another  in  the  approximal  surface  of  a  molar, 
they  should  be  opened  up  and  filled  as  one  cavity.  I  did  not  mean 
this,  however,  to  include  all  cases.  My  language  is,  "  Where  a  crown 
cavity  in  a  bicuspid  or  a  molar  is  but  slightly  separated  from  an  ap- 
proximal cavity,  the  two  should  be  united  and  filled  as  one."  The 
word  slightly  here  indicates  where  I  should  make  an  exception  to  this 
rule.  Where  the  caries  has  originated  in  the  crown,  and  tunneled 
through  to  the  approximal  surface,  we  will  most  frequently  find  occa- 
sion for  treating  differently.     The  management  would  depend  upon 


OXYPHOSPHA  TES  IN  CO  MB  IN  A  TION  WITH  GOLD.     159 


the  size  of  the  approximal  orifice.  If  the  opening  at  that  point  were 
small,  it  will  be  best  not  to  connect  the  two  cavities  further  than  by  the 
tunnel  made  by  the  decay. 

A  condition  of  this  kind  is  seen  in  Fig.  170,  Fig.  171  showing  pos- 
terior view  of  same,  and  is  from  a  case  in  practice.  A  lady  presented 
with  a  leaky  gold  filling  in  the  crown  of  a  first  molar.  Considerable 
decay  was  found  underlying  the  gold,  which  upon  removal  disclosed  the 
fact  that  the  cavity  had  reached  the  posterior  approximal  surface,  the 
opening  there  being  small  and  near  the  gum.  This  tooth  and  the  adja- 
cent molar  were  in  close  contact,  and  it  was  desirable,  because  of  the 
patient's  enfeebled  health,  to  suomit  her  to  as  little  annoyance  as  pos- 
sible. The  idea  of  wedging,  in  order  to  fill  the  approximal  cavity 
separately,  was  abandoned.  The  procedure  was  as  follows.  A  narrow 
strip  was  cut  from  thin  German  silver  and  pressed  between  the  molars. 
Next  a  wooden  wedge  was  driven  between  this  strip  of  metal  and  the 


Fig.  170. 


Fig.  171. 


Fig. 172. 


adjacent  tooth,  so  that  it  was  forced  tightly  against  the  opening  of  the 
cavity,  completely  covering  it.  Amalgam  was  then  introduced 
through  the  crown  cavity  and  packed  against  the  German  silver. 
The  crown  cavity  was  filled  with  gutta-percha,  and  the  patient  dis- 
missed till  the  following  day.  At  her  next  visit  the  crown  cavity  was 
filled  with  gold,  using  the  method  of  employing  oxyphosphate  for 
starting.  This  served  the  additional  purpose  of  separating  the  gold 
from  the  amalgam  already  in  place. 

I  will  introduce  a  second  case  from  practice,  of  a  somewhat  similar 
character,  which  received  different  treatment,  though  following  the 
same  general  principles.  A  lad  of  fourteen  was  in  my  care  for  the 
regulation  of  his  teeth,  which  necessitated  the  contraction  of  the  arch. 
As  a  retainer,  bands  of  pure  gold  were  accurately  fitted  over  the  first 
molars  on  each  side,  and  to  them  was  soldered  a  gold  wire  which, 
iitting  around  the  arch,  restrained  all  the  teeth.  Subsequently  he 
came  in  for  an  examination,  and  I  found  an  old  amalgam  filling  in  the 
crown  of  one  of  these  banded  molars  leaking  badly.  -  Upon  its  re- 
moval I  discovered  the  same  condition  as  last  described,  the  caries 
having  reached  the  posterior  approximal  surface.  This  allowed  the 
gold  band  to  be  seen,  as  is  shown  in  Fig.  172.     This  retaining  fixture 


l6o  METHODS  OF  FILLING   TEETH. 

having  been  permanently  in  place  for  over  a  year,  I  simply  filled  the 
entire  cavity  with  gold,  building  against  the  gold  band  at  the  point 
where  it  was  visible  through  the  approximal  opening.  When  the  time 
came  for  removing  the  retainer,  the  wire  was  cut  and  the  band  around 
this  tooth  allowed  to  remain  in  place  permanently,  appearing  as  an 
open  gold  crown.  This  will  suggest  a  method  which  I  have  in  many 
cases  used  with  success.  That  is,  where  a  molar  is  imperfect,  or  badly 
undermined  along  any  surface,  communicating  with  a  crown  cavity,  a 
band  such  as  in  the  above  case  may  be  made  and  cemented  about  the 
tooth,  before  the  insertion  of  a  filling. 

Where  a  crown  cavity  emerges  at  the  buccal  aspect,  leaving  con- 
siderable dentine  bridging  the  part  between,  it  may  be  filled  with  a 
continuous  gold  filling,  by  first  closing  the  buccal  opening  with  oxy- 
phosphate  and  allowing  it  to  set.  Then  the  crown  may  be  filled,  and 
this  done  the  phosphate  may  be  removed  from  the  buccal  part  and  the 
filling  continued.  With  amalgam  this  would  not  be  necessary.  I 
once  had  a  case  where  the  pulp  had  died,  the  cavity  in  the  crown 
being  quite  extensive.  Removal  of  decay  disclosed  the  fact  that  caries 
had  penetrated  the  palatal  side  of  the  tooth,  forming  a  long  groove 
below  the  gum-line.  A  piece  was  cut  from  German  silver,  which, 
wrapped  around  the  tooth,  allowed  an  extension  to  pass  between  the 
tooth  and  the  gum  at  the  affected  point,  and  so  reached  the  opening. 
This  was  held  in  place  by  winding  flax  thread  around  the  tooth,  and 
the  cavity  was  filled  with  amalgam  from  the  crown,  the  material  being 
packed  against  the  German  silver.  This  avoided  forcing  the  amal- 
gam through  against  the  gum,  and  saved  the  annoyance  of  passing 
burnishers  below  the  gum,  which  when  attempted  caused  profuse 
hemorrhage. 

Crown  cavities  occurring  in  the  lower  jaw,  especially  in  the  sixth- 
year  molars,  are  to  be  treated  under  a  rigid  rule.  No  small  fillings 
should  be  inserted.  Regardless  of  the  smallness  of  the  cavity,  the 
fillings  in  these  teeth  all  look  alike  superficially  ;  all  seem  to  be  large. 
The  only  difference  is  in  the  depth  to  which  they  reach.  In  other 
words,  the  crossed  sulci  should  be  cut  out  freely  from  end  to  end,  if 
there  is  decay  at  any  part  of  either.  Not  only  should  all  carious 
structure  be  removed,  but  the  borders  of  the  cavity  should  be  ex- 
tended into  all  territory  which  is  liable  to  decay  in  the  future. 

Uniting  Teeth  with  Gold  Fillings. 

The  chief  object  of  uniting  two  or  more  teeth  by  continuous  filling 
is  in  connection  with  the  treatment  of  teeth  affected  by  pyorrhea 
alveolaris  where  the  possible  cure  of  the  disease  may  be  deemed  to 
be  dependent  upon  firmly  fixing  one  or  more  loosened  teeth.     The 


UNITING  TEETH  WITH  GOLD  FILLINGS.  i6l 

method  is  sometimes  resorted  to  in  the  incisors,  chiefly  in  the  lower 
jaw.  The  necessity  seldom  arises  except  late  in  life,  and  may  be 
more  safely  relied  upon  where  the  teeth  have  been  worn  away  by 
abrasion  so  that  the  cutting-edges  are  found  to  be  broad.  This  fact 
affords  sufficient  space  in  which  to  make  a  groove  wide  enough  to 
receive  a  wire,  extending  across  all  the  teeth  and  imbedded  in  the 
filling.     The  method  of  procedure  is  as  follows  : 

The  rubber-dam  being  in  position,  extending  over  the  eight 
anterior  teeth,  the  loosened  members  are  firmly  ligated  so  as  to 
assume  the  desired  position,  a  point  of  importance  being  that  the 
teeth  should,  if  possible,  be  so  aligned  that  the  central  axis  of  all 
should  be  in  a  continuous  curve.  The  best  results  will  obtain  where 
the  cuspids  are  included  in  the  union,  and  this  becomes  more  neces- 
sary in  proportion  to  the  looseness  of  the  incisors.  Where  the 
ligatures  firmly,  fix  the  teeth,  the  work  may  be  continued  without 
further  attention  to  this  point ;  often,  however,  it  will  be  found 
advantageous  to  imbed  all  the  teeth  in  oxyphosphate  cement  so  that 
only  the  parts  to  be  filled  protrude  from  the  mass.  Where  any  or 
all  of  the  teeth  are  sore  to  the  touch,  this  additional  support  cannot 
be  overlooked.  The  cutting-edges  of  the  teeth  are  next  to  be  treated 
as  one  long  tooth,  and  a  groove  cut,  so  shaped  that  the  filling  in  each 
separate  tooth  would  be  retained  if  filled  as  a  separate  operation. 
The  filling  is  begun  at  one  end,  in  a  depression  which  firmly  holds 
the  first  pellet,  and  a  thin  but  substantial  floor  to  the  groove  is  built 
throughout  with  narrow  strips  of  heavy  foil,  care  being  taken  to  keep 
the  surface  as  flat  as  possible.  A  three-sided  iridio-platinum  wire  is 
bent  to  shape  so  that  it  nicely  fits  the  groove,  flat  side  down.  It  is 
next  fastened  into  position  by  building  gold  foil  over  the  wire  at  each 
end,  thus  fastening  it  down,  the  newly  added  gold  being  attached  to 
the  gold  floor  which  was  first  laid.  The  filling  is  completed  with 
gold  and  platinum,  great  care  being  necessary  to  thoroughly  pack 
this  material  over  the  wire. 

The  same  general  directions  apply  to  bicuspids  as  well  as  to  molars. 
In  molars,  however,  where  we  have  more  tooth-substance,  larger 
grooves  or  cavities  will  be  advantageous.  We  can  thus  use  a  heavier 
wire  or  bar,  and  wherever  possible  the  bar  should  have  a  cross-piece 
at  each  end,  making  each  end  a  "T  in  shape.  This  will  prevent  the 
teeth  from  separating,  as  might  occur  were  a  single  straight  bar  used,, 
the  filling  possibly  becoming  cracked  where  it  crosses  from  one  tooth 
to  the  other,  and  the  bar  under  the  strain  of  mastication  allowing  mo- 
tion in  the  direction  of  its  length.  Where  it  is  not -feasible  to  use 
the  T  arms,  the  ends  of  the  bar  may  usually  be  bent  like  an  L,  which, 
serves  the  same  purpose. 

Where  the  teeth  at  the  ends  of  the  union  are  themselves  affected 

II 


l62  METHODS  OF  FILLING  TEETH. 

by  pyorrhea,  it  will  commonly  be  best  to  remove  the  pulps,  in  which 
case  a  much  more  permanent  union  may  be  effected  by  having  the 
ends  of  the  bar  bent  so  that  they  enter  the  pulp-canals.  As  the  re- 
moval of  the  pulps  of  teeth  badly  affected  with  this  disease  is  now 
considered  good  practice,  it  will  probably  be  best,  where  the  in- 
cisors are  to  be  united,  to  remove  the  pulps  of  all  the  affected  teeth 
and  solder  extensions  to  the  wire,  one  to  each  canal.  This  method 
will  be  found  serviceable  in  teeth  of  younger  persons,  where  the 
ravages  of  pyorrhea  have  attacked  them  before  the  cutting-edges 
may  have  been  removed  by  erosion.  In  these  cases  the  pulps  are 
removed  from  openings  at  the  lingual  aspect,  and  the  groove  for  the 
reception  of  the  wire  is  cut  along  the  lingual  surface,  thus  connect- 
ing with  the  openings  to  the  canals.  The  wire,  with  its  extensions 
into  each  canal,  becomes  in  effect  a  series  of  staples,  and  the  filling 
process  is  much  simplified,  the  wire  being  set  with  cement  in  each 
canal. 

There  is  a  class  of  cases  which  may  perplex  the  operator  who  deals 
with  one  for  the  first  time,  whereas  the  solution  of  the  problem  is  not 
difficult.  Let  us  suppose  that  a  first  molar  has  been  lost,  and  that 
the  second  bicuspid  has  fallen  backward  into  this  space  until  it  stands 
practically  isolated.  Whether  from  pyorrhea,  or  other  cause,  sup- 
pose that  it  is  quite  loose,  and  that  the  occlusion  with  the  opposite  jaw 
has  accommodated  itself  to  the  abnormal  position  of  the  bicuspid. 
How  shall  this  tooth  be  held  rigid?  The  pulp  is  removed,  and  a  bar 
made  which  extends  across  from  the  first  bicuspid,  through  a  groove 
in  the  second,  reaching  into  a  cavity  cut  in  the  molar.  The  ends  of  this 
bar  are  furnished  either  with  the  J  or  the  L-shaped  arms  as  above 
described,  and  at  the  center  a  stout  extension  passes  down  into  the 
canal  of  the  loose  bicuspid.  Next,  the  spaces  between  the  teeth 
crossed  by  the  bar  are  supplied  with  solid  gold  cusps,  fitted  snugly 
against  the  approximal  surfaces,  soldered  to  the  bar,  and  properly 
occluding  with  the  opposite  jaw.  These  cusps  are  not  to  extend  to 
the  gum,  but  should  go  deep  enough  to  be  of  material  assistance  in 
rigidly  fixing  the  loose  tooth.  This  fixture  is  attached  with  cement 
placed  in  the  canal,  and  the  cavities  above  and  around  the  bar  filled 
with  gold  and  platinum.  Of  course,  where  the  spaces  permit,  porce- 
lain teeth  may  be  fitted. 

In  bridge  pieces  carrying  one  or  two  teeth,  held  in  place  by  gold 
fillings,  much  is  gained  of  course  where  the  canals  of  the  abutments 
can  be  utilized.  Where  the  teeth  are  alive  and  healthy,  the  wanton 
destruction  of  the  plugs  would  rarely  be  other  than  malpractice. 
Where  there  is  sufficient  tooth-structure,  as  in  bicuspids,  the  T  arms 
should  be  resorted  to,  or  better  still,  a  wire  bent  to  the  shape  of  the 
letter  S  or  made  into  a  figure  8  may  be  soldered  to  the  end  of  the 


SENSITIVENESS  AT  THE  TOOTH-NECK.  163 

bar  instead  of  the  simple  J  arms.  Either  of  these  forms  permit  of 
packing  the  gold  very  securely  around  the  ends.  Where  one  abut- 
ment is  an  incisor,  and  there  is  no  possibility  of  utilizing  the  arms, 
then  it  is  of  advantage  to  use  a  screw-plate  and  cut  a  thread  on  the 
end  of  the  bar  which  passes  into  that  cavity.  At  all  events,  some 
precaution  is  necessary  to  prevent  lateral  spreading.  In  all  cases 
the  floor  of  the  cavity  should  be  filled  before  placing  the  bridge, 
which  latter  may  be  tried  in  from  time  to  time,  so  that  as  much  gold 
as  possible  may  be  placed  before  inserting  the  bridge.  In  this  class 
of  bridge-work,  where  the  anchorages  require  so  much  endurance 
on  the  part  of  the  patient,  it  is  essential  that  the  porcelain  faces  be 
of  some  type  of  removable  crown, — a  feature,  too,  which  greatly 
simplifies  the  operation  of  filling. 


CHAPTER    VII. 

Special  Principles  involved  in  the  Preparation  of  Cavities  and 
THE  Insertion  of  Fillings — Sensitiveness  at  the  Tooth-Neck — 
Erosion— Green-Stain— True  Caries— Festoon  Cavities— The 
Labial  Surface— The  Palatal— The  Lingual— Buccal  Cavities- 
Temporary  Fillings— The  Finishing  of  Fillings. 

I  HAVE  divided  cavities  into  three  general  classes  :  approximal, 
crown,  and  surface,  the  last  including  all  parts  not  covered  by  the 
other  two.  Strictly  speaking,  however,  all  three  of  these  terms  were 
intended  to  apply  to  that  portion  of  the  tooth  which  is  normally 
covered  by  enamel.  A  cavity  existing  in  the  root  of  a  tooth,  and  not 
owing  its  inception  to  caries  beginning  at  some  other  point,  is  a  rarity, 
which,  with  a  single  exception,  needs  no  particular  mention  in  this 
work.     This  exception  will  be  alluded  to  later. 

There  is,  however,  a  cavity  which  in  its  earliest  stages  frequently 
demands  our  attention ;  and  this  I  may  as  well  consider  now,  before 
taking  up  surface  cavities  proper. 

Recession  of  the  gum  often  results  in  a  line  of  distinct  sensitiveness 
along  the  neck  of  the  tooth  just  above  the  bulge  of  enamel  at  the 
labial  aspect  of  the  anterior  teeth. 

The  patient  will  report  the  occurrence  of  pain  on  brushing  the 
teeth,  and  that  even  touching  the  part  with  the  finger-nail  produces 
an  unpleasant  sensation.  In  the  earliest  stages  an  examination  may 
reveal  nothing  except  a  corroboration  of  the  facts  stated,  the  tooth 


164 


METHODS  OF  FILLING  TEETH. 


itself  showing  no  signs  either  of  deep  decay  or  of  superficial  softening. 
A  fining  seems  contraindicated  in  the  absence  of  a  cavity,  yet  the 
patient  may  insist  upon  having  relief 

In  order  that  the  condition  may  be  thoroughly  appreciated,  as  well 
as  the  remedy  which  I  shall  advise,  it  will  be  necessary  to  enter  some- 
what into  the  etiology  of  the  condition.  I  have  never  seen  e^iamel 
sensitive  upon  its  outer  surface.  If  others  have  noted  such  a  phenom- 
enon, it  is  sufficiently  anomalous  to  be  unconsidered  in  this  connec- 
tion. I  have  never  seen  cementum  sensitive.  Sensitive  dentine,  how- 
ever, is  common.  Thus,  dentine  being  the  only  hard  tissue  of  the 
tooth  which  is  responsive  painfully,  it  would  seem  to  follow  logically 
that  pain  at  the  neck  of  a  tooth  must  be  due  to  an  exposure  of  the 
dentine.     Fig.  173  represents  a  sectional  view  through  a  cuspid.     It 

Fig.  173. 


is  diagrammatical,  but  is  nevertheless  sufficiently  accurate,  since  in 
making  the  original  of  the  illustration  I  have  produced  the  various 
parts  by  copying  drawings  which  I  made  from  microscopic  specimens 
in  the  laboratory  of  Dr.  Carl  Heitzmann. 

The  first  point  of  interest  to  be  noted  is  that  normally,  at  the  neck 
of  the  tooth,  the  cementum,  c,  overlaps  the  enamel,  e,  just  beneath  the 
free  margin  of  the  gum,  g.  As  this  gum  recedes,  possibly  as  far 
as  the  fine  a,  the  cementum  becomes  exposed  and  gradually  dis- 
appears, thus  leaving  the  dentine  exposed  at  b.  Very  soon  thereafter 
the  part  may  become  excessively  sensitive.  This  leads  to  a  considera- 
tion of  the  dentine,  d,  especially  at  this  point.  Sensitiveness  in  den- 
tine has  long  been  attributed  to  the  dentinal  fiber.  This  fiber,  though 
traced  as  far  as  the  odontoblastic  layer  of  the  pulp,  has  not  been  posi- 


SENSITIVENESS  AT  THE  TOOTH- NECK.  165 

tiveiy  seen  to  anastomose  with  a  nerve-fiber  of  the  pulp  itself.  That 
it  has  the  power  of  transmitting  sensation  is  generally  admitted.  It 
has  also  been  universally  observed  that  dentine  immediately  below  the 
enamel  is  more  sensitive  than  elsewhere.  Exactly  at  this  point  we 
have  what  is  termed  the  interzonal  layer,  as  at  i.  The  fibers  of  the 
dentine  bifurcate  as  they  approach  this  territory  and  enter  it,  after 
which  they  can  be  traced  as  distinct  fibers  only  very  sparsely.  This 
might  tend  to  the  impression  that  this  interzonal  layer  should  be  less 
sensitive  than  the  main  mass  of  the  dentine,  but  there  is  considerably 
more  living  matter  here  than  in  the  denser  portion,  where  the  tubuli 
are  distinct.  Dr.  John  I.  Hart,  in  an  able  paper  on  this  subject,* 
claims  that  exactly  at  the  neck  of  the  tooth  the  character  of  the  interzonal 
layer  changes,  and  that  immediately  underlying  the  cementum  he 
finds  a  granular  layer.  This  I  have  not  myself  seen  ;  but  the  doctor 
admits  that  this  is  very  richly  endowed  with  living  matter,  and  so 
accounts  for  the  sensitiveness. 

The  mere  exposure  of  this  dentine,  however,  would  probably  not 
cause  any  annoyance  to  the  patient.  This  leads  back  to  the  state- 
ment that  after  the  recession  of  the  gum  the  cementum  begins  to  dis- 
appear. I  think  this  is  probably  due  very  largely  to  the  tooth-brush, 
the  cementum  wasting  away  by  friction,  This  view  is  sustained  by 
the  fact  that  though  the  recession  of  the  gum  may  occur  on  the  palatal 
as  well  as  the  labial  side,  the  sensitiveness  will  occur  at  the  labial  only. 
At  least  I  have  never  observed  such  a  disturbance  at  the  neck  on  the 
palatal  side  of  any  of  the  anterior  teeth,  except  when  contact  with  a 
part  of  an  artificial  denture  had  caused  an  abrasion  or  superficial 
caries. 

The  destruction  of  the  cementum,  then,  may  be  chiefly  attributed 
to  the  action  of  the  brush,  and,  therefore,  as  soon  as  the  dentine  is 
reached  it  will  suffer  from  the  same  cause,  so  that  presently  the  living 
matter  of  the  interzonal  or  granular  layer  becomes  exposed.  At 
first  it  may  be  responsive  only  to  contact,  as  when  touched  by  the 
bristles  of  the  tooth-brush  or  by  the  finger-nail.  Later  it  will  give  pain 
when  subjected  to  excessive  heat  or  cold,  or  to  the  action  of  acids  or 
sweets. 

If  taken  in  this  early  period,  the  remedy  is  as  simple  as  it  is  effec- 
tual. With  a  clean,  smooth  burnisher,  rapidly  revolved  in  the  engine, 
burnish  the  affected  part,  using  considerable  pressure,  and  continuing 
until  the  patient  ceases  to  shrink.  If  this  be  thoroughly  done,  the 
operator  and  patient  will  be  astonished  to  observe  that  the  part  can 
be  freely  touched  painlessly.  How  has  it  been  accomplished?  Pos- 
sibly it  is  that  the  burnisher  drags  together  the  gaping  sides  of  the 

*See  Dental  Cosmos,  p.  723,  vol.  xxxiii. 


1 66  METHODS  OF  FILLING  TEETH. 

minute  openings  In  the  dentine,  thus  closing  them  and  covering  up 
the  hving  matter,  which  the  excessive  heat  from  the  friction  may  also 
serve  to  devitalize.  Thus  a  crust  Is  formed  over  the  responsive 
tissue,  so  that  It  Is  shielded.  Fortunately,  If  the  use  of  a  very  soft 
brush  be  adopted,  the  sensitiveness  will  rarely  recur  within  six  months 
or  a  year,  when  the  remedy  may  be  applied  again.  Where  carious 
action  has  actually  begun,  a  superficial  softening  having  supervened, 
the  procedure  Is  slightly  dififerent.  It  Is  at  this  time  that  the  tooth 
will  ache  after  the  use  of  acids  or  sweets,  etc. ,  and  an  irritation  of 
the  living  matter  has  probably  occurred.  Touch  the  part  with  a 
saturated  solution  of  nitrate  of  silver,  and  allow  this  to  remain  for  a 
few  days.  This  will  discolor  the  tooth,  and,  whilst  effectual  In  allay- 
ing pain,  is  a  disfigurement.  It  must  therefore  be  removed  with  a 
corundum,  or  with  a  polishing- point  and  pumice.  This  will  at  the 
same  time  take  away  the  softened  dentine  from  the  surface,  and  the 
sensitiveness  will  again  be  noticed,  though  in  a  lesser  degree.  The 
burnisher  must  consequently  be  resorted  to,  and  persisted  in  till  no 
softness  appears  on  the  surface.  This  may  leave  a  deep  groove,  but, 
especially  with  women,  will  be  preferable  to  an  unsightly  gold  filling. 
Of  course,  where  greater  progress  has  been  made,  so  that  a  distinct 
cavity  Is  produced  by  the  removal  of  softened  dentine  or  decay,  a 
filling  Is  unavoidable. 

This  sensitiveness  at  the  neck  may  also  occur  on  the  molars  ;  and 
here  we  do  sometimes  find  it  along  the  palatal  as  well  as  the  buccal 
side.  It  may  also  result  where  attrition  has  worn  down  the  masti- 
cating surfaces  till  the  interzonal  layer  of  dentine  becomes  exposed. 
This  Is  a  good  place  for  the  free  use  of  the  nitrate- of- silver  treatment. 
The  dam  Is  to  be  applied,  If  possible,  and  the  parts  touched  with  the 
saturated  solution,  which  Is  allowed  to  dry.  I  have  treated  teeth  In 
this  way,  sometimes  renewing  It  two  or  three  times  at  successive  sit- 
tings, until  by  the  blackening  of  the  surface  I  was  assured  that  a 
heavy  deposit  coated  the  parts.  These  teeth  not  only  ceased  to  be 
sensitive,  but  I  have  noticed  that  even  where  carious  action  had 
begun,  the  surface  being  softened,  the  carles  has  been  aborted.  I 
have  also  seen  teeth  which  I  had  treated  in  this  way  five  years  pre- 
viously come  Into  my  hands  again,  when,  mistaking  the  discolora- 
tion for  nicotine  stains,  I  have  proceeded  to  cleanse  them.  In  every 
such  case  the  patients  have  returned  within  a  week,  complaining 
that  the  sensitiveness  had  returned. 

The  condition  which  I  have  been  describing  should  never  be  mis- 
taken for  erosion, — an  error  which  might  be  made  with  the  anterior 
teeth.  Yet  the  distinctions  are  well  marked.  With  erosions  we 
almost  always  have  the  enamel  Involved.  I  might  say  always,  for  the 
exceptions  are  only  where  the  erosion,  starting  upon  the  enamel,  may 


EROSION. 


167 


spread  so  as  to  involve  the  neck.  Again,  the  erosion  will  always  pre- 
sent with  a  sharply  defined  outline,  and  seuiitiveness  rarely  if  ever 
occurs.  This  fact  is  another  evidence  that  the  cupping-out  of  crowns, 
which  are  often  extremely  sensitive,  are  not  erosions.  The  dis- 
turbance at  the  neck,  on  the  contrary,  is  sensitive,  has  no  distinct 
borders,  and  the  enamel  is  never  encroached  upon  until  caries  is 
present. 

Surface  Cavities. — Cavities  upon  the  surfaces  of  teeth,  other  than 
the  approximal,  may  result  from  erosion,  green-stain,  or  caries.  The 
last  may  have  as  contributory  causes,  abrasion,  malformation,  or  re- 
cession of  the  gums. 

Erosion. — The  etiology  of  erosion  is  still  shrouded  in  doubt.  It  is 
probably  a  distant  symptom  of  a  constitutional  disturbance,  which  has 
affected  the  secretions  of  the  mucous  glands  so  that  they  discharge 
mucus  in  which  there  is  an  acid  present,  which  has  an  erosive  influence 
upon  enamel  and  dentine.  It  is  rarely,  if  ever,  seen  upon  the  masti- 
cating or  approximal  surfaces  of  teeth.  It  is  most  common  upon  the 
labial  surfaces  of  incisors,  cuspids,  and  bicuspids  of  the  superior  set, 
and  cuspids  and  bicuspids  in  the  inferior.  It  may  occur,  however, 
upon  any  tooth.  Its  most  distinctive  characteristic  is  that  the  affected 
part  is  hard  and  highly  polished.  Erosion  may  also  be  said  to 
assume  typical  forms,  of  three  general  varieties.  The  most  remark- 
able of  these  is  where  the  disease  eats  out  an  acute  angle,  one  line  of 
which  is  at  right  angles  to  the  surface  of  the  tooth.  This  is  made 
plainer  by  Fig.  174,  which  gives  a  profile  view  of  a  superior  bicuspid, 
the  erosion  showing  at  a,  whilst  in 
Fig,  175,  a,  we  see  the  same  class 
of  erosion  in  a  lower  bicuspid. 
A  point  which  must  have  some 
clinical  significance,  but  which  I 
am  at  a  loss  to  explain,  is  this  :  that 
though  the  one  tooth  here  is  from 
the  upper  jaw,  and  the  other  from 
the  lower,  the  erosions  are  iden- 
tical. In  each  case  the  lijie  of  the  eroded  angle  which  is  at  right  angles 
to  the  labial  stirface  of  the  tooth,  is  at  the  top,  the  obliqice  line  extend- 
ing downward.  In  this  form  of  the  disease,  the  pulp-chamber  is 
frequently  reached,  secondary  dentine,  however,  being  deposited,  so 
that  the  pulp  does  not  become  exposed.  In  a  few  cases  the  crown 
has  been  cut  through  so  far  that  it  has  been  lost  by  fracture.  The 
progress  is  usually  slow. 

A  second,  and  to  my  mind  the  most  dangerous  form  of  the  dis- 
turbance is  an  irregular  concavity.  A  patient  with  a  beautiful  set  of 
teeth  may  come  in  within  three  months  of  his  last  visit,  and  show 


Fig.  174. 


Fig.  175. 


i68 


METHODS  OF  FILLING   TEETH. 


small  eroded  spots  on  the  labial  surfaces  of  several  teeth.  Within  a 
year  they  may  grow  to  thrice  the  size,  and  in  from  five  to  ten  years 
the  dentine  may  be  denuded  from  gum  to  incisive  edge.  Unless  the 
constitutional  disturbance  which  is  behind  this  can  be  controlled,  gold 
fiUings  serve  only  a  temporary  purpose,  if  they  are  beneficial'at  all. 
Fig.  176  shows  a  central  incisor  with  a  point  of  erosion  on  the  labial 
surface.  This  was  filled  with  gold,  and  five  years  later  presented  as 
seen  in  Fig.  177,  the  filling  still  in  place  at  a,  but  entirely  surrounded 
by  erosion,  which  continued. 

The  third  form  is  a  uniform  groove,  which  may  be  deep  or  shallow 
in  proportion  to  its  width,  and  may  be  quite  short,  or  long  enough  to 
extend  from  one  approximal  surface  to  the  other.  They  are  most 
commonly  seen  near  the  gum.  Fig.  178  shows  a  bicuspid  in  which  is 
seen  the  shallow  groove  near  the  gum,  at  a,  whilst  above  it,  at  b,  is 
an  extreme  example  of  the  deep  groove,  appearing  as  though  cut  with 
a  file.  It  is  not  difficult  to  imagine  this  converted  later  into  the  form 
shown  in  Fig.  175,  by  the  fusion  of  the  two. 


Fig.  176. 


Fig.  177. 


Fig.  178. 


Fig.  179. 


Fig.  179  shows  a  singular  case  which  came  under  my  observation, 
and  is  the  extreme  type  of  the  groove.  This  is  a  bicuspid,  and  had 
been  filled  many  years  previously,  the  cusps  having  been  restored  by 
gold  contour,  and  the  root-canals  filled  with  gold.  The  subsequent 
erosion  destroyed  the  labial  surface  of  the  tooth,  grooving  it  out  until 
the  gold  in  the  canal  is  fully  exposed,  showing  relatively  as  indicated 
at  a  in  the  illustration.  Recession  of  the  gum  allowed  the  erosion  to 
include  a  part  of  the  root.  ,  • 

The  above  classification  of  erosions  perhaps  cannot  be  considered 
as  absolute.  Erosions  vary  so  much  that  it  might  be  difficult  in  some 
instances  to  say  to  which  of  these  types  a  special  case  should  belong. 
Nevertheless,  what  I  have  described  are  distinct  types,  notwithstand- 
ing the  fact  that  they  may  be  fused  the  one  into  the  other. 

That  they  are  attributable  to  different  constitutional  disturbances  is 
doubtful,  as  they  may  all  occur  in  the  same  mouth  at  the  same  time. 

Nevertheless,  I  feel  safe  in  the  following  statements.  The  first  con- 
dition frequently  ceases  to  spread  ;  that  is,  erosion  stops.  This  is 
probably  due  to  an  alteration  in  the  health  of  the  individual.     If  this 


EROSION. 


169 


Fig.  180. 


can  be  definitely  known,  cavities  should  be  formed  and  gold  fillings 
inserted.  Because  of  the  peculiar  shape,  it  is  not  difficult  to  deter- 
mine this  point.  The  procedure  is  as  follows  :  Burnish  a  piece  of 
heavy  gold  foil,  No.  120,  into  the  cavity,  allowing 
the  edges  to  extend  slightly  over  the  enamel  borders. 
Then  fill  with  oxyphosphate  mixed  stifif  enough  so 
that  in  pressing  it  into  place  the  gold  will  be  more 
thoroughly  adapted  to  the  cavity.  When  this  is 
set,  remove  it,  and  keep  it  for  reference.  Fig.  180 
makes  the  method  more  intelligible,  the  relation 
between  the  phosphate  and  gold  plug,  a,  and  the 
eroded  part,  being  plainly  shown.  If  a  year  later 
this  plug  exactly  fits  into  the  cavity  of  erosion,  the 
disease  may  be  considered  cured,  and  a  gold  filling 
is  indicated.  When  it  is  here  admitted  that  the  ero- 
sion has  not  spread  in  a  year,  the  question  may  be 
asked.  Why  fill  at  all  ?  The  answer  is,  th^t  though 
I  should  wait  a  year  before  deciding,  I  should  not 
neglect  to  have  the  patient  report  during  that  period.  It  frequently 
occurs  that  after  erosion  ceases,  true  caries  attacks  the  point,  which  is 
readily  understood,  since  a  good  lodging-place  for  debris  is  afforded. 
Hence  the  necessity  for  filling. 

In  the  second  class  of  cases,  one  must  feel  that  interference  by 
filling  can  accomplish  only  one  thing.  By  covering  up  the  eroded 
surface  further  erosion  may  wide7i,  but  cannot  deepen,  the  cavity. 

Two  cases  from  practice  may  be  worth  relating,  though  I  am 
scarcely  prepared  to  assert  that  the  method  adopted  is  of  permanent 
value.  In  both  cases  I  had  to  deal  with  extensive  erosion,  affecting 
all  the  anterior  teeth  of  both  jaws.  In  the  first  case  I  filled  all  of  the 
teeth  on  the  right  side,  above  and  below,  with  gold,  and  all  on  the 
left  side  with  amalgam.  In  the  second  case,  operated  upon  at  about 
the  same  period,  I  filled  the  upper  teeth  on  the  right  side  with  gold, 
and  on  the  left  with  amalgam  ;  in  the  lower  jaw  I  followed  the  reverse 
plan,  using  gold  on  the  left  side,  and  amalgam  on  the  right.  Thus 
in  one  mouth  I  had  the  gold  and  amalgam  on  opposite  sides,  whereas 
in  the  other  both  materials  were  in  both  jaws  on  both  sides.  In  these 
two  cases,  which  have  been  under  my  close  observation  now  for  more 
than  three  years,  there  has  been  no  recurrence  of  erosion  in  any  of 
the  teeth  filled  with  amalgam.  In  one  mouth  erosion  recurred  in  a 
lower  bicuspid,  forming  a  groove  as  seen  in  Fig  178,  b,  the  gold 
filling  having  occupied  the  situation  of  the  groove  a  in  the  same  figure. 
In  an  upper  bicuspid  in  the  same  mouth,  erosion  recurred  as  depicted 
in  Fig.  177,  though  in  a  much  less  marked  degree.  In  neither  case 
was  the  gold  loosened.      In  the  other  mouth,  erosion  recurred  around 


lyo  METHODS  OF  FILLING  TEETH. 

three  of  the  gold  fillings.  Whether  amalgam  is  by  .any  means  a  de- 
tergent of  erosive  action  cannot  be  stated,  but  at  present  I  am  relying 
on  this  material  where  its  appearance  would  not  be  intolerable,  and  I 
may  call  attention  to  the  fact  that  a  highly  polished  amalgam  filling 
is  not  unsightly  near  the  gum-line  in  the  lower  jaw.  If  the  patient 
can  be  seen  twice  a  year,  these  fillings  can  be  readily  repolished  as 
often  as  needed. 

The  groove  variety,  I  think,  is  more  slow  in  its  progress  than 
either  of  the  others.  1  usually  do  not  fill  them  until  they  are  deep 
enough  to  appear  like  cavities,  when  I  insert  gold,  expecting  the  fill- 
ings to  be  lost  in  time,  explaining  the  fact  to  the  patient.  I  have 
seen  such  work  last  so  well,  however,  that  I  am  inclined  to  believe 
that  it  has  the  advantage  of  making  a  slow  disease  even  slower  in 
its  destructive  action.  The  formation  of  all  these  cavities  would  be 
similar  to  those  occurring  from  caries,  which  will  be  described 
later. 

Green-Stain. — Green-stain  is  a  discoloration  or  stain,  greenish  in 
color,  found  upon  the  labial,  buccal,  and  occasionally  upon  the  palatal 
surfaces  of  teeth. 

In  the  first  edition  of  this  work  I  announced  it  as  my  belief  that 
green-stain  was  largely  due  to  the  drinking  of  milk,  the  residuum 
remaining  upon  the  polished  enamel-surfaces  of  the  teeth  in  the  same 
fashion  as  it  does  upon  the  smooth  surface  of  a  glass  tumbler,  becom- 
ing the  initiative  in  a  fermentative  process  resulting  in  the  green-stain. 
In  favor  of  this  theory  I  stated  that  the  stain  is  more  common  in  child- 
hood, children  drinking  more  milk  than  adults  ;  and,  secondly,  I  cited 
the  clinical  fact  that  the  stain  more  frequently  occurs  in  the  upper 
than  in  the  lower  jaw,  which  does  not  oppose  the  milk  theory,  be- 
cause in  drinking  usually  the  lower  lip  covers  and  protects  the  lower 
teeth. 

Since  then  Professor  Miller  has  combated  this  idea,  though  his  main 
argument  was  that  he  had  examined  the  mouths  of  children  in  an 
asylum  where  little  if  any  milk  was  used,  and  had. found  the  usual 
proportion  of  green-stain.  My  own  opinion  was  merely  a  tentative 
one,  and  is  quite  possibly  erroneous.  Nevertheless,  though  we 
abandon  the  suggestion  that  the  green-stain  is  a  direct  product  of  a 
fermentation  thus  set  up,  it  may  not  be  impossible  that  this  residuum 
of  milk  offers  a  favorable  medium  for  the  cultivation  of  a  bacterium 
which  does  produce  the  stain.  At  all  events,  no  solution  of  the  still 
unsolved  problem  can  be  received  as  final  which  does  not  more  satis- 
factorily explain  why  green-stain  is  more  commonly  found  upon  the 
labial  surfaces  of  the  superior  incisors  than  in  any  other  situation,  in 
spite  of  the  fact  that  if  the  teeth  are  brushed  at  all  exactly  these  four 
teeth  receive  the  greatest  proportion  of  such  cleansing. 


GREEN-STAIN.  1 7 1 

I  also  advocated  the  idea  that  green-stain  is  a  menace  to  the  enamel, 
being  directly  responsible  for  the  decalcifications  so  frequently  asso- 
ciated with  it.  This  Dr.  Miller  also  disputes,  and  since  the  publica- 
tion of  his  article  {Dental  Cosmos,  April,  1894)  a  series  of  discussions 
have  ensued,  men  of  equal  reputation  and  ability  for  clinical  obser- 
vation being  arrayed  on  opposite  sides  of  the  question.  In  brief 
Professor  Miller's  opinion  is  that,  "It  always  remains  restricted  to 
the  enamel-cuticle,  and  does  not  encroach  upon  the  enamel,  every 
trace  of  the  stain  peeling  off  along  with  the  enamel-cuticle.  Pits, 
fissures,  grooves,  or  scratches  on  the  surface  of  the  tooth  predispose 
to  the  deposition  of  green-stains  ;  likewise  a  surface  roughened  by 
the  action  of  acids.  This  has  led  some  to  suppose  that  the  stain  was 
the  cause  of  the  roughness,  while  as  a  matter  of  fact  the  sequence 
has  been  just  opposite," 

The  fact  that  the  stain  can  be  peeled  off  with  the  enamel- cuticle, 
and  is  never  seen  in  the  subjacent  enamel,  is  no  proof  that  decalcifi- 
cation of  the  enamel  is  not  a  consequent  result  of  the  superimposed 
stain.  The  beautiful  work  of  Dr.  J.  Leon  Williams  has  disclosed 
microscopic  strata  of  bacteria  lying  upon  the  surface  of  enamel  which 
has  not  sufficiently  decalcified  to  permit  the  entrance  of  the  bacteria 
themselves,  whilst  to  a  considerable  depth,  even  reaching  to  the  den- 
tine, the  processes  of  decalcification  are  visibly  proceeding  dependent 
upon  the  secretions  of  the  identical  bacteria  which  have  not  yet  them- 
selves penetrated  the  territory.  In  similar  manner  it  is  conceivable 
that  the  green-stain  itself  may  not  pass  beyond  the  cuticle,  and  that 
nevertheless  the  cuticle  may  be  no  barrier  to  products  which  have  the 
power  of  decalcifying  enamel. 

I  am  willing  to  admit  that  a  roughened,  grooved,  or  pitted  surface 
may  invite  deposition  of  green-stain,  but  I  cannot  find,  as  a  logical 
corollary  of  this,  that  all  roughness  found  under  green-stain  must 
have  occurred  prior  to  the  deposition.  Certainly  it  would  seem  to 
me  that  Professor  Miller  has  not  yet  disproven  the  long-prevailing 
theory  that  decalcification  found  under  green-stain  is  a  sequence, 
rather  than  a  pre-existent  condition. 

No  theory,  however  scientifically  probable,  viewed  from  a  purely 
theoretical  experimental  standpoint,  can  be  accepted  as  conclusive 
unless  it  deals  with  and  explains  clinical  facts,  especially  such  as 
are  commonly  observed  and  frequently  recorded  by  all  classes  of 
operators.  In  this  connection,  a  clinical  fact  of  importance  is  that 
green-stain  not  only  occurs,  but  it  reacrs.  It  is  not  uncommon  for 
thoroughly  capable  men  to  remove  green-stain,  and,  .finding  decalci- 
fication of  enamel,  to  polish  that  away,  especial  pains  being  taken  to 
restore  a  normally  lustrous  surface.  Within  a  few  months  the  patient 
may  return,  with  more  green-stain,  under  which  again  is  found  the 


1 7  2  ME  THODS  OF  FILLING   TEE  TH. 

zone  of  decalcification.  The  theorist  may  argue,  that  here  again  the 
decalcification  appeared  first  and  the  deposit  of  stain  was  thus  invited  ; 
yet  it  is  significant  that  we  rarely  if  ever  observe  this  decalcification 
prior  to  its  being  covered  by  the  stain,  while  conversely  it  is  a  most 
common  occurrence  to  find  the  decalcification  occurring,  and  re- 
peatedly recurring  under  deposits  of  the  stain. 

In  some  mouths  we  remove  green-stain  and  find  the  enamel  per- 
fect. It  is  consequently  true  that  the  stain  may  be  deposited  upon 
enamel  which  has  not  suffered  any  decalcification.  In  other  cases  we 
find  after  removal  of  the  stain  that  there  is  considerable  decalcifica- 
tion. How  shall  we  determine  whether  or  not  this  existed  prior  to 
the  deposit,  or  whether  it  has  occurred  since  ?  Let  us  assume  that 
the  decalcification  exists  first,  and  that  the  stain  is  superimposed  upon 
it.  Will  the  presence  of.  the  stain  inhibit  further  decalcification  ?  If 
so,  disintegration  of  enamel  should  never  progress  in  the  presence  of 
green-stain  ;  and,  moreover,  unaffected  enamel  so  covered  should  be 
protected,  so  that  the  tooth  at  that  point  should  be  immune  to  caries. 
But  we  often  find  true  caries  associated  with  green-stain,  so  that  it 
cannot  be  a  protection.  If,  on  the  other  hand,  we  admit  that  green 
stain  is  neither  abortive  nor  protective,  then  it  follows  that  underlying 
green-stain  we  may  have  decalcification  of  enamel,  progressive  in  its 
nature,  and  if  neglected  succeeded  by  caries.  This  is  the  clinical 
experience  of  all  operators. 

Consequently,  whichever  proposition  finally  maintains,  and  which- 
ever be  the  sequence  of  events,  the  fact  remains  that  green-stain 
must  peremptorily  be  removed  wherever  found,  because  it  may  cover 
decalcified  enamel,  and  thus  disguise  the  fact  that  the  tooth  needs 
prompt  attention. 

If  green-stain  be  removed  with  a  rubber  disk  and  pumice-powder, 
the  enamel  will  be  found  chalky  in  color  and  consistence.  Fig  i8i 
shows  a  central  incisor  from  which  the  stain  has  been  removed,  the 
stippling  at  a  indicating  where  the  enamel  is  found  decalcified.  If 
taken  in  time,  this  will  be  so  superficial  that  it  may  be  stoned  away 
with  a  corundum,  without  penetrating  to  the  dentine,  in  which  case 
it  is  advisable  to  follow  that  course,  and  then  highly  polish  the  enamel. 
Later,  the  underlying  surface  will  be  found  as  in  Fig.  182,  where  we 
see  three  small  cavities  surrounded  by  an  area  of  decalcification,  as 
indicated  by  the  stippling  in  the  illustration.  There  is  nothing  to  be 
done  here  except  to  unite  the  cavities,  removing  all  of  the  defective 
enamel,  and  fill  with  gold.  Fig.  183  is  introduced  to  show  how 
great  devastation  may  be  occasioned  by  green- stain,  and  is  a  case 
from  practice,  found  in  the  mouth  of  a  miss  often.  This  is  a  central 
incisor  in  which  a  large,  irregular  cavity  appears  in  the  center  of  the 
labial  face,  the  boundaries  of  which,  however,  do  not  limit  the  destruc- 


TRUE  CARIES.  173 

tion,  the  stippling  again  indicating  an  area  of  decalcification.  In  the 
mouth  in  question  both  centrals  were  thus  injured,  and  similar  though 
smaller  cavities  were  found  in  both  laterals  and  both  cuspids.  The 
pulps  being  alive,  it  was  thought  best  to  fill  these  teeth  with  gold, 
notwithstanding  the  consequent  disfigurement. 

Along  the  buccal  surfaces  of  both  upper  and  lower  molars  green- 
stain  plays  the  saddest  havoc.  It  is  unfortunately  not  uncommon  to 
find  what  at  first  seems  to  be  a  small  cavity,  the  apparent  walls  of 
which,  however,  will  be  so  thoroughly  decalcified  that  they  are  readily 
broken  down  with  an  excavator.  Where  this  is  the  case,  it  is  well  to 
first  remove  the  green-stain  with  a  corundum,  and  thus  be  enabled  to 
determine  what  is  the  real  limitation  of  the  destruction.  Starting 
with  a  small  cavity,  extension  which  removes  all  decalcified  structure 
may  result  in  a  cavity  which  almost,  if  not  quite,  encircles  the  tooth 
near  the  gum-margin.  I  have  seen  the  entire  buccal  surface  so 
destroyed,  with  narrow  extensions  reaching  the  palatal  surface  around 
both  approximal  sides. 

Fig.  181.  Fig.  182.  Fig.  183. 


True  Caries. — Caries  may  produce  surface  cavities  on  any  of  the 
teeth,  though  I  have  never  seen  such  a  cavity  in  the  lingual  surface 
of  the  lower  incisors.*  It  may  follow  the  depredations  begun  by 
erosion,  or  by  green-stain.  It  may  occur  in  the  grooves  formed  by 
abrasion  after  recession  of  the  gum,  at  the  tooth-neck.  It  may  result 
from  malformations,  which  have  made  crevices  where  we  should 
have  perfectly  smooth  surfaces.  But  most  commonly  we  will  find  the 
typical  festoon  cavity  in  the  anterior  teeth,  and  buccal  cavities  in 
molars. 

In  Fig.  184  is  shown  the  usual  festoon  cavity  as  it  will  be  found  in 
the  central  incisor.  The  retentive  formation  has  been  sufficiently  de- 
scribed in  Figs.  13,  14,  15,  16.  This  is  a  cavity  which  out  of  the 
mouth  would  be  most  readily  filled,  but  because  of  the  fact  that  the 
upper  border  is  often  at,   or  under,  the  gum-margin,  will  be  found 

*  Since  writing  the  above,  a  girl  of  ten  presented  with  a  distinct  cavity 
involving  only  the  lingual  surface  of  an  inferior  lateral  incisor. — The 
Author- 


174  METHODS  OF  FILLING  TEETH. 

most  trying.  Where  the  gum-border  so  covers  the  cavity  that  it 
would  be  impossible  to  apply  the  dam  successfully,  the  procedure  is 
to  pack  a  roll  of  cotton  under  the  free  margin  as  tightly  as  possible, 
and  then  fill  the  cavity  with  gutta-percha,  so  that  the  cotton  will  be 
kept  in  place.  When  the  cavity  is  so  shallow  that  gutta-percha 
would  not  be  retained,  the  cotton  should  be  tied  in  place  with  a  linen 
or  silk  ligature.'  In  twenty-four  hours  the  gum  will  have  yielded 
sufficiently  to  allow  the  placing  of  the  dam.  Or  where  the  tooth  is 
of  favorable  shape  fill  the  cavity  with  gutta-percha,  and  slip  a  ring, 
cut  from  rubber  tubing,  over  the  tooth  and  force  it  under  the  gum.* 
This  will  produce  the  same  result,  but  should  never  be  attempted 
without  warning  the  patient  that  in  case  she  should  be  prevented 
from  returning  at  the  next  appointment,  this  rubber  ligature  must  be 
removed,  else  there  would  be  danger  of  serious  injury  to,  if  not  loss 
of,  the  tooth.  Festoon  cavities  in  the  incisors  and  cuspids  of  both 
jaws  should  be  filled  with  gold  wherever  possible,  and  it  will  be  pos- 
sible in  more  cases  as  the  dentist  forms  the  habit  of  making  the  en- 
deavor to  place  gold  instead  of  the  less  reliable,  though  more  man- 
ageable, plastics.  Where  the  cavity  extends  so  far  under  the  gum 
that  the  rubber-dam  cannot  be  placed,  that  portion  may  be  filled 
with  amalgam,  and  the  remainder  with  gutta-percha.  At  the  next 
sitting  the  dam  is  easily  placed  and  the  gutta-percha  replaced  with 
gold.  Where  the  cavity  is  excessively  sensitive,  it  may  be  well  at 
times  to  fill  with  gutta-percha,  probationally  ;  but  within  six  months, 
at  most,  the  gold  should  replace  the  temporary  filling.  I  have  no 
faith  in  oxyphosphate  or  oxychloride  in  this  situation,  except  for 
the  most  temporary  purpose, — as,  for  example,  supposing  that  the 
regulation  of  a  set  of  teeth  be  desirable  without  delay,  and  the  fix- 
tures would  interfere  with  gold  filling.  It  may  be  well  to  fill  with 
oxyphosphate  until  the  regulation  has  been  completed  and  the 
opportunity  occurs  to  place  gold. 

A  handsome  gold  filling  is  less  frequently  seen  at 
Fig.  184.  ^^   festoon  than   in  other   positions.     The   cavity 

itself  being  easy  to  fill,  this  proves  how  much  the 
proximity  of  the  gum  interferes  with  success. 

Taking  such  a  cavity  as  is  shown  at  Fig.  184, 
the  dam  must  be  placed,  and  a  clamp  arranged  so 
that  the  upper  margin  is  freely  exposed  to  view. 
Begin  by  filling  the  distal  retaining  pit  at  a,  and 
then  fill  the  opposite  one  at  b.  Next  select  a  pellet 
long  enough  to  reach  from  the  gold  at  one  side  to  that  at  the  other. 
Fasten  at  both  ends,  and  then  pack  it  against  the  upper  wall  c,  which 

*See  page  31. 


FES  TOON  CA  VITIES.  ■  1 7  5 

reference  to  Fig.  15  will  show  has  no  undercut.  The  absence  of  an 
undercut  allows  the  use  of  a  foot-plugger,  and  the  pellet  may  be 
packed  against  and  over  the  upper  border.  A  second  and  third 
pellet  similarly  packed  will  avoid  the  danger  of  slipping  of  the  clamp. 
Besides,  by  this  -method  the  most  important  part  of  the  cavity  is  filled 
early,  before  any  moisture  may  have  crept  in,  and  the  continuance 
of  the  filling  is  made  easy.  For  this,  heavy  foil  should  be  relied 
upon  exclusively,  and  fine  points  with  a  hand-mallet  make  the  densest 
filling. 

The  most  difficult  festoon  cavity  is  such  as  is  shown  at  Fig.  185, 
where  we  see  a  cuspid,  the  root  of  which  has  been  exposed  by  the 
recession  of  the  gum,  and  subsequent  caries  has  encroached  upon  it 
to  the  gum-margin.  Because  of  the  extensive  recession  at  the  labial 
side,  with  possibly  no  recession  at  the  palatal,  it  will  be  difficult  to  fit 
a  clamp  so  that  it  will  not  slip.  With  one  or  other  of  the  various 
forms,  however,  it  may  be  done.  The  retentive  arrangement  is  dif- 
ferent here.  It  consists  of  extensions  at  a,  a,  as  before,  but  less  deep. 
Grooves  are  to  be  made  along  the  borders  b,  b,  growing  shallower  as 
they  meet  at  c.  The  filling  is  begun  in  the  distal  pit,  and  extended 
along  one  groove  toward  the  point  c,  then  down  the  next  groove, 
and  into  the  opposite  pit.  Then,  starting  at  c,  pellets  may  be  employed 
to  cover  the  floor,  building  across  from  groove  to  groove  until  the 
bottom  of  the  cavity  is  completely  covered.  Then  resort  to  heavy 
foil,  and  work  from  the  point  c  toward  completion.  Use  fine  points 
and  the  hand-mallet,  to  obtain  the  densest  surface. 
Perhaps  I  should  explain  why  I  prefer  the  hand-  ^^'  ^  ^' 

mallet  to  the  engine  or  electric  mallet  in  these 
cavities.  It  is  because  the  best  results  are  attain- 
able with  these  power- mallets  only  when  a  rest  for 
thie  hand  holding  them  can  be  had.  When  working 
in  the  crowns  of  the  superior  teeth,  the  hand  rests 
upon  the  chin.  In  the  lower  jaw  the  power-mallet 
is  less  convenient,  yet  a  finger  of  the  left  hand 
may  usually  be  made  to  serve  as  a  rest  or  guide  to 
the  mallet-point.  This  is  still  more  difficult  in  festoon  cavities,  for 
which  reason  I  recommend  the  hand-mallet.  The  others  will  make 
good  filHngs  where  the  operator  has  acquired  the  skill  to  manage 
them,  but  where  he  finds  their  use  awkward  he  will  probably  get  a 
poor  result  if  he  persists  in  using  them  with  the  erroneous  idea  that 
they  make  better  fillings.  Once  more  I  say  it  is  not  the.  instrument, 
but  the  man,  who  accomplishes  success. 

The  preparation  of  festoon  cavities  in  bicuspids  does  not  vary  from 
that  in  the  cuspids.  In  the  superior  jaw  they  should,  in  my  opinion, 
.always  be  filled  with  gold  ;  but  in  the  lower,  though  gold  is  prefer- 


1/6  METHODS  OF  FILLING   TEETH. 

able,   a  properly  placed  and  properly  polished  amalgam  filling  will 
do  good  service. 

Where  a  festoon  cavity  is  connected  with  an  approximal  one,  the 
former  should  be  filled  first.  In  these  cases,  build  the  gold  well  up 
along  the  gingival  border,  so  that  when  the  clamp  is  removed  to  allow 
access  to  the  approximal  cavity,  the  dam  will  not  slip  down .  A  liga- 
ture may  then  be  applied,  and,  forced  above  the  gold,  will  easily  be 
tied  securely  so  that  all  will  be  kept  dry.  Where,  however,  it  is  de- 
cided to  fill  the  approximal  cavity  with  amalgam,  the  reverse  order 
must  be  followed.  The  amalgam  must  be  placed  first,  and  thoroughly 
polished  at  the  next  sitting,  vv?hen  gold  may  be  placed  in  the  festoon, 
the  part  which  is  to  be  readily  seen. 

Before  leaving  festoon  cavities,  I  may  mention  that  on  more  than 
one  occasion  I  have  seen  eight  or  ten  such  cavities  occur  suddenly 
in  the  mouth  of  a  person  suifering  from  an  acute  attack  of  gastritis. 
They  are  also  common  in  connection  with  a  chronic  gingivitis,  and 
fillings  in  such  teeth  will  fail  unless  the  gingivitis  is  properly  treated 
and  cured.  Again,  there  is  a  species  of  deposit  found  in  the  mouths 
of  persons  who  may  be  scrupulously  cleanly,  which  seems  to  have 
the  power  of  producing  caries.  This  deposit  is  most  often  seen  at 
the  labial  festoon  of  the  lower  anterior  teeth.  It  is  whitish,  and  of 
a  creamy  consistency.  After  properly  filling  the  teeth,  the  patient's 
attention  should  be  attracted  to  this  condition,  and  special  brushes 
recommended,  the  bristles  of  which  will  reach  and  cleanse  these 
places.     Without  this  precaution  the  best  filling  will  fail. 

Cavities  upon  the  labial  surfaces  are  rare,  and  mainly  due  to  a  mal- 
formation, which  either  produces  a  crevice,  or  else  poorly  calcified 
enamel.  The  depredations  assume  all  manner  of  irregular  shapes, 
but  two  rules  cover  them  all.  Where  the  cavity  is  single,  prepare 
it  approximately  circular,  or  with  the  borders  of  the  best  curve  which 
will  include  all  of  the  carious  region  without  unnecessary  enlargement. 
Secondly,  where  there  are  two  or  more  small  cavities,  they  are  not 
to  be  united  except  they  be  so  near  that,  filled  as 
a  single  cavity,  the  gold  will  not  be  more  con- 
spicuous than  where  each  is  treated  separately. 
(See  Figs.  21,  22.)  A  single  illustration  will  suffice 
to  show  the  method  of  management.  In  Fig.  183 
was  shown  an  irregular-shaped  cavity  surrounded 
by  decalcified  enamel.  Fig.  186  shows  the  same 
prepared  for  filling.  To  accomplish  this,  first  use  a 
fine  corundum  over  the  surface,  removing  all  of  the 
decalcified  territory,  which  is  so  superficial  that  after  grinding  it 
away  the  underlying  enamel  may  be  polished.  This  will  leave  a  clear 
indication  of  what  the  limits  of  the  cavity  necessarily  must  be.     The 


FESTOON  CA  VITIES. 


177 


next  step  is  to  take  a  sharp  excavator,  and  with  a  scraping  motion 
remove  all  of  the  chalky  substance.  This  will  leave  the  outlines  even 
more  clearly  defined.  Now  a  sharp  rose  bur  may  be  used  in  the  engine, 
and  a  slight  groove  made  around  the  whole  extent  of  the  cavity.  This 
groove,  however,  is  not  at  first  made  in  the  nature  of  a  retainer  or 
undercut,  but  is  rather  to  perfect  the  edges  and  curve  of  the  border. 
With  the  same  bur  all  caries  may  be  cut  from  the  cavity,  if  any  has  been 
left  after  the  use  of  the  excavator.  The  groove  must  next  be  deepened 
in  order  to  acquire  retentive  shaping.  This  is  done  laterally  only,  and 
in  a  direction  sufficiently  oblique  that  the  pulp  shall  not  be  endan- 
gered. The  dotted  lines  at  a,  a  show  the  manner  of  extending  the 
grooves,  and  indicate  that  the  deepest  points  are  farthest  from  the 
incisive  edge.  Along  the  incisive  border  of  the  cavity  no  under- 
cutting is  to  be  attempted  ;  but  the  original  groove  must  have  been 
deep  enough  to  produce  a  distinct  shoulder  here,  and  avoid  any- 
thing like  a  bevel.     This  also  must  be  true  of  all  edges,  which  are 


Fig.  I 


to  be  at  right  angles  to  the  labial  surface,  and  not  beveled.  This  can 
be  better  explained  by  showing  a  sectional  view  of  the  right  and  the 
wrong  way  to  treat  this  cavity.  Fig.  187  shows  a  section  through  a 
central  incisor,  in  which  the  cavity  has  been  properly  shaped.  At  a,  a 
is  seen  the  deepest  part  of  the  retaining  groove,  and  its  relation  to  the 
pulp  and  to  the  orifice  of  the  cavity  can  be  noted.  At  b,  b  are  shown 
the  right-angled  edges.  In  the  same  kind  of  cavity,  in  Fig.  188,  the 
edges,  b,  b,  are  prepared  with  a  bevel.  By  this  method  it  is  plain 
from  the  figure  that  the  retainers,  a,  a,  are  weaker  than  in  the  other, 
whilst  it  is  also  true  that  the  thin  edge  of  gold  which  will  be  the  result 
will  eventually  turn  up  and  break,  so  that  the  borders  of  the  filling 
become  defective  and  leakage  follows.  Moreover,  in  polishing,  the 
result  pictured  in  Fig.  47  would  easily  occur.  To  fill  this  cavity  with, 
gold,  use  pellets  in  one  groove  and  then  in  the  other.  This  done,, 
build  across,  uniting  them  and  covering  the  floor  with  heavy  foil,  with: 
which  complete  the  filling.  Care  should  be  used  not  to  proceed  too> 
rapidly,  so  that  thorough  condensation  may  be  had,  as  well  as  per- 
fection of  border.  It  is  a  pleasure,  when  such  a  filling  is  placed,  to  be 
able  to  polish  it  like  a  mirror,  and  have  the  borders  so  well  made  that 


1 78  METHODS  OF  FILLING   TEETH. 

even  under  a  strong  magnifying  glass  they  appear  as  fine  as  a  hair. 
This  will  rarely,  if  ever,,  be  possible  where  the  beveled  edge  is 
depended  upon. 

Fig.  189  shows  a  curious  cavity  which  occurred  once  in  my  prac- 
tice, and  I  introduce  it  because  the  method  of  management  will  be 
instructive.  This  cavity  originated  in  one  of  those  pits  which  are 
not  uncommon  upon  cuspids,  and  which  result  from  malformations. 
It  presented  as  a  small  but  distinct  cavity.  On  preparing  it,  to  my 
surprise  I  noted  that,  however  deep  I  went,  the  bottom  of  the  little 
pit  still  showed  as  a  black  spot.  Using  a  mouth-mirror,  I  examined 
the  palatal  side,  and  there  found  a  corresponding  pit,  at  a  point 
exactly  opposite  to  that  on  the  labial  face.  Further  exploration  dis- 
closed the  fact  that  caries  starting  in  each  had  met,  so  that  when 
removed  there  was  a  hole  completely  through,  from  the  labial  to  the 
palatal  surface.  Here  was  a  cavity  without  any  bottom  to  it.  The 
dam  being  in  place,  I  stopped  up  the  palatal  orifice  with  oxyphos- 
phate,  which  I  allowed  to  set  hard.  I  then  filled  the  cavity  in  the 
labial  face,  after  which  I  removed  the  oxyphosphate  and  completed 
the  filling  from  that  side,  succeeding  in  obtaining  cohesion  for  my 
first  pellet  with  the  gold  packed  from  the  other  side,  so  that  when 
finished  there  was  a  solid  gold  filling  from  side  to  side.  This  idea, 
conceived  in  connection  with  this  particular  cavity,  has  been  useful  in 
many  directions.      I  have  elsewhere  alluded  to  it. 

The  common  cavity  at  the  palatal  aspect  of  the  anterior  teeth  is 
simple  enough,  except  that  great  caution  is  necessary  to  prevent 
injury  to  the  pulp.  This  cavity  may  be  met  in  either  central,  lateral, 
or  cuspid,  but  will  most  often  be  found  in  laterals,  occurring  in  the 
sulcus.  Its  preparation  is  best  shown  by  a  sectional  view  such  as  Fig. 
190,  where  we  see  how  near  any  cavity  at  this  point  must  approach 
the  pulp.  I  prefer  a  small  rose  bur  to  open  the  cavity,  but  any  soft 
decay  which  may  be  present  must  be  removed  with  small  spoon  exca- 
vators. As  soon  as  the  limits  of  the  cavity  are  reached,'  it  will 
probably  be  found  to  be  of  retentive  shape  ;  but  if  not,  extension 
must  be  carefully  attempted,  and  must  be  directed  parallel  to,  or  away 
from,  the  walls  of  the  pulp-chamber,  as  seen  in  the  figure.  I  have 
seen  a  palatal  cavity  neglected  till  it  presented  as  shown  in  Fig.  191. 
If  we  look  at  this  from  a  sectional  view,  as  in  Fig.  192,  we  see  at  once 
that  the  pulp  is  in  danger.  Nevertheless,  this  cavity  is  quite  similar 
to  that  shown  in  Figs.  186  and  187  as  occurring  on  the  labial  surface. 
As  in  that  case,  grooves  may  be  made  laterally  at  a,  «,  escaping  the 
pulp.  But,  unlike  the  labial  cavity,  these  grooves  can  be  connected 
in  the  palatal  cavity,  because  of  the  fact  that  on  this  side  there  is  a 
bulge  which  permits  this  procedure  in  safety.  The  retaining  groove, 
therefore,  becomes  a  horse-shoe,  as  indicated  by  the  dotted  lines  a,  a. 


LINGUAL  CAVITIES.  1/9 

As  in  the  labial  cavity,  a  slight  shoulder  must  be  formed  toward  the 
incisive  portion,  in  order  to  avoid  a  bevel,  and  so  assure  a  good  border 
to  the  gold.  The  same  cavity  in  a  cuspid  is  much  simpler.  After 
forming  the  groove,  deep  extensions  may  be  made  at  the  gingival 
angles,  owing  to  the  fact  that  there  is  a  sufficient  amount  of  tooth- 
substance  to  make  it  safe  to  form  strong  anchorages.  There  is  another 
difference  between  the  labial  and  the  palatal  cavity,  which  must  be 
noted.  Of  two  cavities  having  the  same  depth,  the  palatal  will  reach 
nearer  to  the  pulp  than  the  labial.  This  is  because  the  labial  surface 
is  convex,  whilst  the  palatal  is  concave.  Consequently  in  palatal 
cavities  it  is  often  wiser  to  adopt  the  oxyphosphate  method  of  starting 
the  gold  filling.  Where  this  is  done,  the  gold  is  pressed  into  the  mass 
of  oxyphosphate  toward  the  incisive  edge.  When  set,  the  oxyphos- 
phate is  removed  from  the  retaining  grooves  and  the  gold  extended 
into  them,  thus  securing  the  filling  without  special  dependence  upon 
the  adhesive  property  of  the  plastic,  which  is  inserted  as  an  insulator. 

Fig.  190.  Fig.  191. 


m 


A  lingual  cavity  in  the  bicuspids  or  molars  is  a  rarity,  and,  when  found, 
usually  extends  along  the  gum-border.  In  nine  cases  out  of  ten  an 
ill-fitting  clamp  has  caused  the  mischief  The  lingual  surfaces  of 
almost  any  of  the  lower  teeth  may  almost  be  said  to  be  exempt,  save 
where  the  clamp  induces  decay.  This  is  perhaps  because  the  tongue 
and  fluids  of  the  mouth  keep  the  parts  washed  and  cleansed.  Never- 
theless, I  have  seen  long,  narrow  cavities,  partly  under  the  gum,  all 
along  the  Hngual  surfaces  of  lower  molars.  Their  preparation  may 
require  that  they  be  packed  with  cotton  for  a  day,  in  order  that  the 
gum  may  be  forced  away.  This  accomplished,  a  rose  bur  which  will 
cleanse  the  cavity  of  decay  will  usually  leave  it  retentive  in  shape.  If 
not,  a  slight  extension  at  each  end  is  all  that  is  needed.  Here  is  a 
place  where  I  might  almost  say  gold  should  never  be-employed.  To 
insert  a  perfect  gold  filling  in  such  a  position,  with  all  the  obstacles 
offered  by  situation,  saliva,  and  presence  of  the  tongue,  would  require 
extraordinary  ability,   and  even  then  would   be  accomplished  at  an 


1 80  ME  THODS  OF  FIL  L ING   TEE  TH. 

expense  of  time  and  pain  that  scarcely  excuses  the  effort.  An  amal- 
gam fining,  on  the  contrary,  may  be  placed  with  rapidity  and  ease, 
and  if  properly  polished  afterward  will  serve  all  purposes. 

In  the   superior  jaw  similar  cavities  are  more  common,  and  at  the 
same  time  less  difficult.     I  will  introduce  here  a  case  from  practice 
which  offered  unusual  features.    Fig.  193  shows  a  first  molar  in  which 
is  seen  a  narrow  cavity,  <2,  along  the  palatal  side 
P  near  the  gum,  whilst  a  second  cavity,  b,  appears 

at  the  palato-approximal  angle.  At  first  glance 
one  would  naturally  say  that  they  should  be 
connected  and  filled  as  one  cavity.  This  I  could 
not  do,  for  the  reason  that  there  was  great  diffi- 
culty in  placing  the  dam.  The  twelfth-year 
molar  had  not  sufficiently  erupted  to  retain  the 
clamp,  which  therefore  was  necessarily  placed 
over  the  affected  tooth.  Again,  this  tooth  was  so 
conical,  and  both  of  the  cavities  were  so  near  the  gum,  that  I  found 
it  impossible  to  place  the  dam  and  tie  a  ligature  before  placing  the 
clamp.  Neither  did  I  succeed  in  tying  a  silk  around  the  tooth  after 
placing  the  clamp.  As  a  consequent  result,  I  found  that  though  I 
could  force  the  dam  back  with  the  clamp  so  that  I  could  fill  either 
cavity,  moisture  would  leak  in  through  the  other.  In  this  dilemma  I 
filled  the  "cavity  b  with  gutta-percha  temporarily,  then  placed  the  dam 
and  filled  the  cavity  a  with  gold,  subsequently  filling  the  other.  I 
filled  these  cavities  with  gold,'  for  the  reason  that  the  teeth  were 
excessively  sensitive,  and  the  young  man  was  obliged  to  wear  an 
obturator,  which  needed  clasps  to  hold  it  in  place.  I  felt  satisfied 
that,  if  filled  with  amalgam,  the  gold  clasps  in  contact  with  amalgam 
in  this  special  instance  would  prove  mischievous.  As  I  decided  to  fill 
the  two  cavities  separately,  I  could  not  form  any  extension  in  either 
at  the  end  near  the  slight  separation  of  dentine  at  c,  without  under- 
mining that  point.  I  therefore  made  an  extension  at  the  opposite 
ends  in  each,  and  formed  slight  undercuts  along  the  length  of  the 
cavities.  In  each  case  the  first  pellet  was  packed  into  the  pit  at  the 
end,'  and  the  gold  built  forward  toward  c.  The  patient  was  tipped 
back  so  that  I  could  get  direct  view  of  the  work  looking  across  the 
mouth,  the  tooth  being  upon  the  left  side.  These  two  fillings  were 
placed  three  years  ago,  and  though  a  fixture  with  clasps  has  been 
worn  constantly  since,  no  annoyance  has  been  reported. 

Buccal  cavities  are  difficult  or  simple  in  proportion  as  they  are 
large  or  small,  sensitive  or  otherwise,  and  near  to  or  distant  from  the 
gum.  The  simplest  form  is  the  small,  almost  circular  cavity  found  in 
the  buccal  sulcus,  oftener  in  the  lower  than  in  the  upper  teeth.  Their 
preparation  is  easy,  necessitating  the  use  of  a  rose  bur  which  will  not 


BUCCAL   CAVITIES.  l8l 

quite  enter  the  orifice,  thus  shaping  the  borders  at  once  as  it  is  pressed 
through  into  the  dentine.  The  removal  of  all  carious  material,  and 
a  slight  internal  enlargement,  will  suffice  where  amalgam  is  to  be  used. 
For  gold,  I  should  make  slight  extensions  obliquely  in  opposite  direc- 
tions ;  this  not  so  much  as  a  retentive  precaution  as  to  facilitate  filling, 
since  the  cavity  so  formed  will  be  more  readily  managed  than  one 
which  is  perfectly  regular  and  round.  There  is  a  strong  temptation 
here  to  wedge  in  a  few  large  pellets,  burnish,  and  call  the  tootli  filled. 
The  true  method  is  to  use  small  pieces  here  as  elsewhere.  I  should 
choose  gold  for  all  such  cases,  except  where  the  youth  of  the  patient 
might  make  it  advisable  not  to  impose  a  lengthy  operation  ;  then  use 
amalgam,  explaining  that  gold  will  be  inserted  later  in  life. 

Where  the  sulcus  is  well  marked  it  should  be  cut  out,  the  cavity 
being  extended  toward,  but  not  necessarily  into,  the-crown.  This  will 
produce  an  oblong  filling.  The  retentive  formation  in  such  cases 
would  be  an  extension  toward,  the  gingival  end  of  the  cavity  and 
lateral,  but  slight  undercutting,  effected  with  a  wheel  bur.  There 
should  be  no  undercut  toward  the  crown,  lest  by  weakening  that 

Fig.  194.  Fig.  195. 


point  fracture  result  under  the  forces  of  mastication.  Larger  cavities 
may  be  met,  of  all  conceivable  shapes.  There  may  be  two,  or  even 
more,  distinct  cavities  in  the  buccal  surface  of  a  single  tooth,  and  in 
each  instance  the  operator  will  be  called  upon  to  connect  them  or  fill 
•each  separately,  as  his  judgment  shall  dictate.  The  main  fact  will 
be  to  determine  whether  the  fillings  will  be  better  retained  separately, 
■or  in  one  cavity.  Fig.  194  presents  a  good  study.  Three  cavities 
are  seen  in  the  buccal  surface  of  a  molar.  The  smaller  one,  «,  is  in 
the  sulcus,  and  quite  near  it  is  another,  b,  extending  along  the  gum- 
border.  At  ^  is  a  third,  which  almost  encroaches  upon  the  approxi- 
mal  surface,  being  near  the  angle.  Here  it  is  plain  that  if  in  cavity  a 
my  instruction  to  make  a  retaining  extension  at  the  gingival  end  were 
obeyed,  the  drill  would  emerge  within  the  cavity  b.  True,  the  smaller 
cavity  could  be  filled,  depending  alone  upon  lateral  undercutting  ;  but 
when  cavity  b  is  similarly  prepared  it  would  be  found- that  the  separa- 
tion between  the  two  would  be  extremely  frail.  Here,  then,  it  would 
be  best  to  unite  and  fill  the  two  as  a  single  cavity.  Cavity  c,  however, 
is  distant,  and  in  sufficiently  sound  territory  to  permit  of  filling  it 
.separately.     Fig.  195  shows  the  tooth  prepared  for  filling.     The  dotted 


1 82  METHODS  OF  FILLING   TEETH. 

lines  a,  a,  indicate  the  retaining  extensions  depended  upon  for  the 
larger  cavity,  whilst  in  the  smaller  there  is  merely  a  general  undercut, 
slight  toward  the  crown,  and  deep  enough  toward  the  gingiva  to 
allow  the  first  pellet  to  be  wedged  securely,  if  gold  is  to  be  used. 
The  choice  of  gold  or  amalgam  might  depend,  as  before,  upon  the 
age  of  the  patient,  or  it  might  be  decided  in  accordance  with  the 
difficulty  met  with  in  placing  the  dam,  and  the  amount  of  moisture. 

The  general  arrangement  of  the  larger  cavity  in  Fig.  195  is  the  one 
to  be  depended  upon  in  all  ordinary  buccal  cavities.  This  is,  exten- 
sions at  the  anterior  and  at  the  posterior  gingival  angles,  with  grooves 
following  the  other  borders,  decreasing  in  depth  as  the  crown  is  ap- 
proached. This  applies  more  particularly  to  cavities  resulting  from 
true  caries.  Those  found  under  green-stain  will  be  much  more  per- 
plexing. To  illustrate,  I  will  give  two  examples.  The  first  is  seen  in 
Fig.  196,  where,  the  stain  having  been  removed,  we  find  three  small 
cavities  along  the  gum-border,  whilst  the  enamel 
p.  ,  between  and  around  them  is  more  or  less  decal- 

cified, as  indicated  by  the  stippHng.  The  prepara- 
tion of  this  necessitates  the  free  use  of  a  bur,  form- 
ing a  single  cavity  which  will  include  the  entire 
affected  area.  This  may  result  in  an  oblong  cavity 
along  the  gum-border  having  nearly  parallel  bor- 
ders. More  commonly,  however,  the  enamel  will 
be  found  softened  toward  the  crown  along  the 
sulcus,  so  that,  when  prepared,  the  cavity  will  be 
approximately  shaped  like  the  larger  one  in  Fig.  195.  A  most  dis- 
heartening condition  is  where,  whilst  extending  the  cavity  in  the 
direction  of  the  decalcified  territory,  it  is  found  that  one  or  both 
approximal  surfaces  have  become  affected.  The  rule,  however,  is 
not  to  be  relaxed,  even  though  the  procedure  as  directed  will  lead 
the  dentist  entirely  around  the  tooth,  thus  forming  a  cavity  com- 
pletely encircling  it.  This  occurred  to  me  once,  and  I  found  much 
difficulty  in  placing  amalgam,  until  I  hit  upon  a  method  which  led 
me  out  of  the  dilemma.  The  difficulty  was  that  after  packing  the 
amalgam  into  the  posterior  approximal  part  of  the  cavity,  thence  into 
the  buccal,  and  so  around  into  the  anterior  approximal,  as  soon  as  I 
'endeavored  to  fill  the  palatal  part  I  found  myself  dislodging  that 
already  packed.  Add  to  this  the  inroads  of  moisture,  because  of 
the  fact  that  I  was  obliged  to  depend  upon  the  napkin,  and  it  is  seen 
that  the  amalgam,  becoming  wet,  could  not  properly  be  forced  back 
into  place.  I  tried  beginning  at  different  points,  but  invariably  when 
I  came  to  completing  the  circle,  dislodgment  resulted.  Finally  I 
succeeded  thus  :  I  fashioned  a  band  of  German  silver,  somewhat 
wider  than  the  cavity.     I  began  by  filling  the  palatal  part  of  the 


BUCCAL  CAVITIES. 


183 


cavity,  packing  the  material  part  way  into  the  approximal  portions. 
Next  I  placed  my  band  in  position  around  the  tooth,  covering  the 
amalgam  already  in  position,  and  allowing  the  two  ends  to  extend 
forward    between     the     adjacent 

teeth.    Around  this  band  I  placed  Fig.  197. 

waxed  flax  thread,  the  ends  lying 
loose.  The  condition  at  this  point 
is  shown  in  Fig.  197,  which  gives 
the  buccal  side  of  the  tooth  still 
unfilled,  the  relation  of  the  band 
and  flax  being  seen.  The  filling 
was  continued  from  the  posterior 
approximal  part  around  into  the 
buccal,  when  the  band  was  bent 
down  over  it.  Then  the  anterior 
part  was  similarly  treated.  When 
both  ends  of  the  band  were  thus 

turned  down,  the  flax  was  tied,  securely  holding  the  band  in  place, 
whilst  as  it  was  drawn  tight  it  compressed  all  the  amalgam  into  the 
cavity  uniformly  and  simultaneously,  even  forcing  out  a  slight  sur- 
plus of  mercury.  This  was  left  in  position  until  the  next  visit.  Since 
then  I  have  frequently  resorted  to  this  method  of  tying  a  band  around 
an  amalgam  filling  where  similar  conditions  existed,  even  though  they 
have  been  less  extensive.  It  is  a  good  precautionary  measure  where 
amalgam  is  placed  in  a  large  but  shallow  buccal  cavity,  as  well  as  in 
many  other  conditions  of  anomalous  shape,  where,  after  filling,  there 
might  be  danger  of  fracture  before  the  mass  has  hardened. 

The  second  type  of  cavities  found  in  connection  with  green-stain 
is  where  the  entire  surface  seems  more  or  less 
decalcified.  Fig.  198  gives  an  extreme  case. 
Where  the  depredation  is  less,  so  that  the  crown 
is  not  so  nearly  approached,  the  borders  are  simply 
to  be  formed  into  regular  curves,  and  the  retaining 
arrangement  will  be  the  same  as  in  Fig.  195,  a,  a. 
Where  the  decalcification  has  been  as  great  as  shown 
in  Fig.  1 98,  it  will  generally  be  wiser,  if  not  actually 
necessary,  to  extend  the  cavity  into  the  crown,  and 
then  form  a  groove  under  all  borders.  In  many 
instances  this  will  be  made  simpler  by  the  presence  of  a  filling  in 
the  crown,  which  can  then  be  removed. 

Only  in  the  smallest  buccal  cavity,  found  under  green-stain,  would 
I  attempt  a  gold  filling.  With  the  larger,  and  especially  where  the 
gingival  border  passes  beneath  the  gum-margin,  I  prefer  and  advise 
amalgam.     An  alloy  which  has  a  percentage  of  copper  in  it  has  done 


Fig.  ic 


1 84  METHODS  OF  FILLING   TFETH. 

better  service  in  my  practice  than  any  other.  No  filhng,  however, 
will  endure,  if  green-stain  supervenes,  as  the  enamel  around  it  will 
be  readily  attacked  and  destroyed,  as  in  the  first  instance. 

There  is  one  other  kind  of  cavity  which  I  promised  to  describe, 
though  not  strictly  a  surface  cavity.  In  fact,  it  may  scarcely  be 
called  a  cavity  at  all,  being,  if  anything,  two  cavities. 

In  the  mouths  of  old  people,  recession  of  the  gum  not  infrequently 
progresses  to  an  extent  which  would  seem  to  menace  the  tooth. 
So  much  of  the  root  is  exposed  to  view  that  it  is  marvelous  that 
the  tooth  should  not  be  loose.  Yet  often  we  find  such  teeth  quite 
firm,  although  in  the  molar  region  the  recession  has  been  so  ex- 
tensive that  the  bifurcation  is  plainly  in  view.  As  a  result  of  this, 
a  lodging-place  for  food  being  afforded,  occasionally  caries  attacks 
the  inner  sides  of  the  roots,  until  the  pulps  being  approached  some 
pain  is  felt,  and  the  patient  comes  in  for  relief. 
„  Any  endeavor  to  prepare  separate  cavities  in  each 

root  would  be  unwise,  for  even  if  successfully 
filled  the  space  between  the  bifurcation  would 
continue  to  act  as  a  repository  for  debris,  so  that 
caries  would  recur.  I  treat  this  space  as  though 
it  were  a  cavity,  simply  removing  as  much  caries 
as  possible,  when  a  naturally  retentive  shape  will 
result.  Where  the  gum  is  irritated  so  that  it 
bleeds  easily,  I  like  gutta-percha,  and  prefer  the 
pink  to  the  white.  Where  the  gum  is  firm,  and 
the  pulps  not  exposed,  or  else  dead,  I  fill  with 
amalgam.  My  method  is  to  cut  a  piece  of  clean  tin  foil  of  such  a  shape 
that  it  can  be  placed  between  the  roots,  covering  the  gum,  thus 
forming  a  floor  against  which  to  pack  the  amalgam.  When  the  filling 
is  in,  the  projecting  end  of  tin  is  turned  up  and  burnished  into  the 
amalgam.  In  Fig.  199  we  see  the  space  between  the  buccal  roots 
of  a  molar,  and  at  a  the  tin  foil. 

Temporary  Fillings. 

• 

Passing  from  permanent,  I  may  profitably  discuss  temporary  fill- 
ings. By  temporary  fiUing  I  do  not  mean  a  probational  filling. 
The  latter  term  should  imply  a  filling  placed  in  a  tooth  where  some 
doubt  exists  as  to  the  advisability  of  inserting  a  permanent  filling  of 
metal.  It  is  therefore  usually  of  oxyphosphate  or  gutta-percha. 
Whilst  in  a  measure  intended  to  serve  a  temporary  purpose,  the  fact 
that  the  tooth  is  in  a  doubtful  condition  of  health  renders  it  impera- 
tive that  the  filling  should  be  placed  securely  and  thoroughly,  so  that 
it  may  remain  undisturbed  as  long  as  possible,  thus  affording  the 
tooth  ample  time  for  full  restoration  to  such  a  state  of  health  that  it 


TEMPO RAR \ '  FILLINGS.  1 8 5 

will  no  longer  be  doubtful  whether  the  final  filling  of  metal  may  be 
inserted. 

Temporary  fillings,  then,  are  those  which  cover  dressings  placed 
within  a  cavity  for  medication  ;  or  those  inserted  to  tide  over  a  few 
days  until  more  convenient  to  fill ;  to  force  the  gum  away  from  cavity- 
borders,  or  for  similar  strictly  temporary  purposes. 

The  man  who  indifferently  packs  in  a  temporary  filling,  with  the 
idea  that  "  it  is  only  for  a  day,"  leaving  surfaces  rough  and  edges 
overlapped,  is  a  sloven.  Moreover,  he  is  careless  of  the  comfort  and 
interests  of  his  patient.  Nowhere  is  the  axiom  truer  that  if  a  thing 
is  worth  doing  it  is  worth  doing  well. 

The  most  important  temporary  fillings  are  those  which  cover  arsen- 
ical dressings.  Arsenic  which  is  not  thoroughly  sealed  within  a  cav- 
ity may  cause  serious  damage,  the  more  so  as  it  must  be  allowed  to 
run  its  course,  which  may  involve  the  entire  bony  socket  of  the  tooth, 
so  that  the  tooth  itself  is  finally  lost.*  The  first  caution,  therefore,  is 
to  observe  that  where  a  cavity  presents  partly  filled  by  hypertrophied 
gum-tissue,  arsenic  should  not  be  applied  at  the  first  sitting,  unless 
special  reason  should  make  it  essential,  and  no  need  of  such  haste 
would  excuse  the  procedure  unless  the  hemorrhage  consequent  upon 
the  removal  of  the  hypertrophied  tissue  could  be  absolutely  con- 
trolled. Ordinarily  a  sharp  lancet  should  be  used  for  removing  this 
•excessive  growth,  and  a  saturated  solution  of  nitrate  of  silver  very 
carefully  applied  to  the  remainder.  A  dressing  carrying  some  medica- 
ment which  will  act  soothingly  upon  the  aching  pulp  should  then  be 
applied,  and  this  covered  with  a  temporary  filling.  I  may  as  well  say 
at  once  that  sandarac  varnish  on  cotton  is  a  filthy  combination  to  place 
in  the  mouth.  In  a  few  cases  it  will  serve  better  than  anything  else, 
but  in  the  great  majority  of  instances  it  can  and  should  be  dispensed 
Avith.  Its  main  advantage  is  when  it  is  desirable  to  force  resistant 
gum-tissue  away  from  a  cavity- border,  when  usually  it  will  serve  the 
purpose  perhaps  better  than  more  cleanly  fillings. 

In  the  case  above  described  I  should  use  the  temporary  stopping 
furnished  at  the  depots,  which  is  a  combination  of  gutta-percha  and 
wax.  This  is  to  be  had  of  two  colors,  pink  and  white.  For  teeth 
which  will  peremptorily  need  attention  at  the  next  sitting,  use  the 
pink,  whilst  when  a  point  is  reached  where  the  tooth  may  be  allowed 
a  few  days'  rest,  use  the  white.     In  this  way  the  dentist  can  tell  at  a 

■^  Where  serious  results  obtain  from  poisoning  the  gum  with  arsenic,  the 
treatment  is  to  dress  the  part  locally  with  tincture  of  iron  ( Tinctura  Ferri 
Chloridi),  and  to  administer  internally  the  hydrated  oxide  of  iron  {Ferri  Oji:- 
iduni  Hydratuni),  or  better  still,  the  same  preparation  with  magnesia  {Ferri 
Oxiditm  Hydratmn  cmn  lilagtiesia) . 


1 86  METHODS  OF  FILLING  TEETH. 

glance  from  the  color  of  the  temporary  stopping  whether  the  tooth 
requires  immediate  attention,  or  whether  it  may  be  passed  whilst 
others  are  filled. 

In  the  case  being  discussed,  then,  the  pink  stopping  would  be 
used.  At  the  next  sitting  this  would  be  removed,  as  well  as  the 
cotton  under  it,  and  it  would  be  found  that  the  gum  would  be  in  such 
a  condition  that  arsenic  could  be  inserted.  I  will  pause  here  to  state 
that  I  am  not  discussing  the  advisability  of  using  arsenic,  but  am 
simply  telling  how  to  use  it  where  the  dentist  does  depend  upon  it. 
The  arsenic  being  placed  carefully  upon  the  point  of  exposure  of  the 
pulp,  the  temporary  stopping  must  be  made  so  soft  that  it  can  be 
placed  without  undue  pressure.  If  it  seems  doubtful  that  this  can  be 
accomplished,  it  will  sometimes  be  better  to  use  wax,  which  can  be 
made  m^uch  more  plastic.  There  is  one  point  to  be  emphasized. 
Where  the  exposure  is  in  connection  with  an  approximal  cavity,  care 
must  be  observed  that  the  temporary  stopping  is  not  crowded  below 
the  gum,  as  this  will  often  cause  more  pain  than  that  experienced  from 
the  arsenic.  With  warm  burnishers  this  filling  should  be  trimmed  to 
proper  shape,  and  made  thoroughly  smooth.  It  should  approximately 
restore  contour,  and  should  not  be  so  full  that  it  would  interfere  with 
occlusion.  Often  when  the  cavity  is  of  poor  shape,  the  burnisher 
may  be  made  so  warm  that  it  slightly  melts  the  stopping,  when  if 
passed  along  the  borders  all  around,  it  will  compel  the  adherence  of 
the  material. 

There  will  occur  cases  where  the  cavity  is  of  such  a  nature  that 
though  the  dentist  desires  to  use  arsenic,  he  will  recognize  at  once 
that,  if  covered  with  temporary  stopping,  the  dressing  will  most  pro- 
bably be  displaced.  The  procedure  in  these  cases  is  to  have  the 
parts  as  dry  as  possible,  with  dam  or  napkin  as  is  most  feasible,  and 
after  applying  the  arsenic,  cover  with  a  thin  oxyphosphate,  which, 
adhering  to  the  cavity,  leaves  an  assurance  of  safety.  The  cavity  can 
be  shaped  properly  for  retaining  the  permanent  filling,  of  course,  the 
trouble  in  the  first  instance  being  that  excavation  whilst  the  pulp  is 
aching  would  be  painful. 

After  the  removal  of  a  pulp,  or  where  the  pulp  has  been  dead  for 
any  length  of  time,  so  that  the  cavity  is  necessarily  deep,  especially 
in  molars,  the  temporary  filling  need  not  be  exclusively  of  temporary 
stopping.  In  large  approximal  cavities,  considerable  cotton  may  be 
placed  over  that  which  carries  the  medicine,  and  only  the  cuter  part 
covered  with  the  temporary  stopping.  This  renders  subsequent 
removal  less  troublesome.  Again,  where  a  large  opening  in  the 
crown  ie  present,  in  addition  to  a  fair  proportion  of  temporary  stop- 
ping, it  will  be  well  to  use  gutta-percha  for  the  exposed  surface,  as 
that  material  will  better  withstand  the  force  of  mastication. 


THE  FINISHING  OF  FILLINGS.  \%7 

Where  it  is  desired  to  fill  a  large  cavity  loosely,  and  yet  seal  it  up 
sufficiently  to  keep  it  clean  and  protected  from  the  ingress  of  food, 
cotton  dipped  in  chloro-percha  will  be  found  much  better  than  cotton 
and  sandarac.  When  cotton  and  sandarac  is  to  be  used,  as  for  pressing 
away  resistant  gum-tissue,  the  cotton  should  be  barely  touched  to  the 
varnish.  Then  open  the  pellet,  and  fold  it  again  so  that  the  sandarac 
is  inside.  This  will  make  a  more  cleanly  plug,  whilst  giving  the 
outer  cotton  a  chance  to  swell  by  absorbing  moisture. 

The  Finishing  of  Fillings. 

The  final  success  or  failure  of  a  fiUing  largely  depends  upon  the 
finishing  or  polishing.  A  number  of  points  in  connection  with  the 
various  materials  are  of  special  interest. 

Gold. — A  gold  filling,  when  dismissed,  should  appear  like  solid  metal, 
smooth  at  every  point  and  highly  polished.  Unless  there  is  good 
reason  for  postponement,  the  finishing  should  immediately  follow  the 
insertion  of  the  filling,  before  removal  of  the  dam.  Exception  to  the 
rule,  so  far  as  the  removal  of  the  dam  is  concerned,  would  be  where 
its  presence  would  interfere  with  the  polishing,  or  where  nothing  is 
gained  by  leaving  it  in  place.  The  judgment  of  the  operator  would 
decide.  Approximal  fillings  should  be  built  out  so  full  that  after 
removing  the  excess  the  exact  contour  would  be  restored,  whilst  the 
surface  of  the  gold  would  be  sufficiently  dense  to  permit  the  highest 
polish.  This  requisite  at  once  banishes  the  matrix.  Whether  in  the 
anterior  or  in  the  posterior  teeth,  superior  or  inferior,  I  like  sand- 
paper for  this  work,  and  prefer  the  disk  on  the  engine- mandrel  to  the 
strip,  though  both  will  be  required  to  meet  all  cases.  I  believe  the 
more  common  practice  is  to  use  the  disk  with  the  sand  side  facing 
away  from  the  engine  hand-piece  which  holds  the  mandrel.  Occa- 
sionally such  a  position  will  be  peremptorily  needed.  Ordinarily  I 
recommend  that  it  be  placed  exactly  the  other  way.  With  the  sand 
side  facing  the  hand-piece,  and  sufficient  practice  to  acquire  dexterity, 
the  operator  will  find  that  he  can  manage  the  greatest  variety  of  fill- 
ings. I  can  reach  and  polish  without  other  instrument  the  following  : 
Anterior  and  posterior  approximal  surfaces  of  incisors,  cuspids,  bicus- 
pids, and  first  molars,  and  the  posterior  surfaces  of  second  and  third 
molars ;  labial  surfaces,  especially  including  festoon  cavities,  and 
often  the  palatal  surfaces.  After  the  disk  has  been  used  a  little  so  that 
it  becomes  pliable,  I  can  trim  a  filling,  shaping  approximal  angles, 
without  flattening.  Where  the  tooth  is  long,  and  wide  at  the  crown, 
I  can  reach  the  gingival  margin  of  the  filling  by  pressing  the  disk 
against  the  adjacent  tooth,  which  compels  it  to  run  as  though  con- 
caved. In  many  inaccessible  places  I  compel  the  disk  to  accomplish 
my  purpose  by  holding  it  against  the  part  with  a  flat  burnisher  pressed 


1 88  METHODS  OF  FILLING   TEETH. 

against  its  reverse  side.  In  fact,  the  disk  on  the  engine  in  my  hands 
is  more  useful  than  any  other  finishing  appHance.  I  may  say  here 
that  in  spite  of  the  undoubted  ingenuity  which  has  been  displayed  in 
the  invention  of  disk-carriers,  the  best  for  all  practical  purposes  is 
still  the  original  simple  screw-mandrel.  Instead  of  using  a  screw- 
driver, however,  the  disk  may  be  placed  or  removed  by  having  the 
mandrel  in  the  engine,  and  holding  the  disk  whilst  the  engine  is  started 
quickly. 

After  using  a  medium  grade  of  disk  for  taking  off  the  surplus  mass 
of  gold,  follow  with  one  made  from  the  finest  pouncing-paper.  This 
will  produce  a  good  polish.  Nevertheless,  a  higher  luster  still  should 
be  attained  by  use  of  a  strip  of  chamois  well  chalked.  For  this  the 
best  material  is  what  is  known  as  "  whiting." 

I  do  not  like  files,  either  between  the  teeth  or  on  labial  surfaces. 
In  the  former  they  are  apt  to  leave  flat  planes,  and  in  any  event  they 
make  scratches,  which  must  be  removed  finally  with  the  sand-paper, 
so  that  the  disk  may  as  well  be  chosen  at  the  outset.  Occasionally  a 
file  may  be  needed  for  making  sufficient  space  in  which  to  revolve  a 
disk  or  pass  a  strip  ;  still,  even  in  these  cases  I  prefer  a  saw,  which, 
having  no  cutting  sides,  removes  only  the  rough  excrescences  which 
prevent  the  ingress  of  the  sand- paper.  The  approximal  trimmer  is 
a  humane  and  valuable  instrument.  Where  the  cervical  margin 
reaches  to  or  passes  the  gum-margin,  the  over-build  of  gold  should 
be  removed  carefully  with  the  approximal  trimmer  rather  than  with 
a  sand-paper  strip  or  disk,  either  of  which  will  so  wound  the  gum  that 
not  only  will  it  remain  in  a  state  of  irritation  for  several  days,  but 
frequently  recession  is  induced.  This  instrument  is  also  essential  for 
the  finishing  of  festoon  fillings.  In  these  cases  it  will  often  be  better 
to  remove  the  dam  as  soon  as  the  filling  is  placed,  for  the  reason  that 
the  clamp  interferes  with  the  work.  With  care,  a  fine  finish  may  be 
achieved  without  wounding  the  gum.  This  is,  however,  a  difficult 
place  to  contend  with.  With  the  approximal  trimmer  remove  the 
excess  of  gold  carefully,  even  though  that  may  mean  slowly,  per- 
fecting the  gingival  margin  and  working  from  the  gum  toward  the 
incisive  end  of  the  tooth,  thus  avoiding  wounding  the  gum  and 
consequent  hemorrhage.  The  gold  trimmed  to  approximately  proper 
proportions,  resort  to  the  smallest  disks,  placed  on  the  mandrel  as 
before  directed.  Placing  the  edge  of  the  disk  near  the  gum,  slight 
pressure  will  cause  it  to  bend,  so  that  as  it  is  revolved  it  finishes  the 
surface  of  the  gold,  the  edge  of  the  disk  if  required  even  passing 
under  the  gum-margin  without  wounding  it.  A  final  polish  may 
be-  produced  with  the  polishing-powders  on  soft-rubber  disks,  or  in 
connection  with  wood  points.  The  rubber  cup.  Fig.  200,  is  invalu- 
able. 


THE  FINISHING  OF  FILLINGS.  1 89 

In  the  crowns  of  bicuspids  and  molars,  I  like  finishing  burs  and 
burnishers  in  the  engine  when  the  fillings  are  small.  Where  they 
are  of  medium  or  large  size  I  use  them  first,  for  the  reason  that  a 
more  thoroughly  dense  surface  is  obtained  by  burnishing.  But  for  a 
final  finish  I  do  not  admire  the  irregular  surface  left  by  the  burnisher. 
I  therefore  depend  upon  small  fine  corundums,  Hindostan  and  Ar- 
kansas stones,  finishing  with  pumice  and  chalk,  used  one  after  the 
other  on  the  soft- rubber  disk. 

Amalgam. — The  same  general  rules  of  aiming  at  and  obtaining 

a  lustrous  polish  are  to  be  observed  with  this  much-abused  material. 

The  approximal  trimmer,  however,  will  not  avail,  and  for  this  reason 

the  gingival  margin  should  be  made  as  nearly  perfect  as  possible 

whilst  the  material  is  yet  plastic.     The  sand-paper  disk  will  do  much 

along  this  part  of  the  approximal  surface,  but  will  not  always  reach 

the  extreme  gingival  margin.    Here  a  fine  finishing  file  having  a  small 

end,  somewhat  similar  to  the  approximal  trimmer,  will  serve  well, 

the  final  finish  being  given 

with   a   spatula   cut  from  t^, 

^  .  Fig.  200. 

orange-wood,  and  used  m  ^KKk 

connection  with  the   pol-         w-,_. „,-,, ^j-  _^  lilHlli         k 

ishing-powders.    In  crown       Tbbt-i ifiifi,,iiirT-— ,^^^^^^  ||HI|i|  ^^' 

and  large  contour  fillings,  ^^ 

after  using  the  rubber  disk  with  pumice 
and  then  with  chalk,  nothing  makes  an 
amalgam  filling  so  handsome  as  the  use 
of  the  small  engine  brush- wheel,  of  mod- 
erate stiffness,  used  first  with  moistened 
pumice  and  then  with  dry  chalk.  I  dis- 
miss this  class  of  fillings  resembling  a 

mirror  in  color  and  luster,  and  they  keep  their  handsome  appearance 
a  long  time,  remaining  forever  smooth,  though  getting  dull  in  time. 

Oxyphosphate. — When  used  as  a  permanent  filling,  this  material 
should  be  allowed  to  set  thoroughly  hard  before  any  attempt  is  made 
to  trim  it  to  shape,  and  when  shaped  a  final  finish  may  be  made  with 
the  pouncing-paper  disk,  followed  by  the  chamois  strip  without 
chalk.  The  dam  being  still  in  place,  the  filling  should  be  thoroughly 
coated  with  chloro-percha,  which  should  be  allowed  to  harden  by 
the  evaporation  of  the  chloroform  before  the  dam  is  removed.  If 
this  rule  is  properly  observed,  this  film  of  chloro-percha  will  often  be 
found  upon  the  filling  two  weeks  later.  Thus  the  material  has  been 
protected  from  moisture  until  hardened  to  a  density  not  otherwise 
attainable. 

G2dta-percha. — This  material  is  trimmed  to  shape  with  warm  bur- 
nishers, and  then  quickly  hardened  by  applying  cold  water.     After 


igo  METHODS  OF  FILLING  TEETH. 

this,  if  an  examination  shows  that  there  is  an  overlap  under  the  gum- 
margin,  dip  floss  silk  in  chloroform,  and  slipping  it  between  the  teeth 
(supposing  it  to  be  an  approximal  cavity),  move  it  back  and  forth. 
This  will  remove  the  excess  without  disturbing  the  filling,  as  might 
occur  if  the  use  of  heated  burnishers  were  essayed  again. 


CHAPTER    VIII. 

Methods  of  Filling  the  Canals  of  Pulpless  Teeth— A  Study  of 
TooTH-RooTs— Methods  of  Gaining  Access  to  and  Preparing 
Canals— Methods  of  Cleansing  Root-Canals— When  and  How  to 

^FiLL  Root-Canals. 

''  Teeth  are  filled  that  they  may  be  saved  ;  that  is,  a  tooth  which 
is  attacked  by  caries  is  in  danger  of  destruction  and  final  loss,  and  a 
filling  is  inserted  in  the  hope  of  saving  it  from  this  result.  If  a  tooth 
which  simply  has  a  cavity  in  it  is  in  a  precarious  condition,  how 
much  more  must  this  be  true  where  the  pulp  has  died  ?  One  might 
almost  say  that  a  tooth  which  is  pulpless  is  half  lost.  Its  future 
depends  upon  the  insertion  of  a  proper  root-filling ;  and  where  it 
receives  unskillful  attention  in  this  direction,  only  a  small  chance  exists 
of  its  long  remaining  a  healthy  member  of  the  arch. 

The  loss  of  the  pulp  is  not  in  itself  the  cause  of  disaster,  for  pulp- 
less teeth  may  remain  healthy  and  useful  indefinitely.  The  trouble 
is  that  if  the  dead  pulp  be  left  in,  its  putrescence  becomes  a  source  of 
excitation  which  usually  results  in  pericementitis,  probably  followed 
by  alveolar  =abscess.  The  remedy  lies  in  the  thorough  removal  of 
the  pulp,  the  hygienic  cleansing  and  sterilizing  of  the  canal,  and  the 
insertion  of  a  root- filling  which  will  completely  replace  the  pulp, 
mechanically  filling  the  chamber. 

I  may,  then,  at  the  outset  take  up  a  consideration  of  the  obstacles 
which  will  hinder  the  thoroughness  of  root-filHng.  There  are  skillful 
men,  who  are  also  reliable,  who  will  unhesitatingly  claim  that  they 
fill  all  roots  to,  or  very  nearly  to,  their  apices.  This  would  involve 
such  treatment  of  the  buccal  roots  of  superior  molars,  and  the  mesial 
roots  of  inferior  molars,  which  are  usually  admitted  to  be  most  diffi- 
cult. Other  men  will  admit  that  they  are  not  so  successful,  but  feel 
assured  that  they  can  manage  all  anterior  teeth.  That  any  men  prac- 
ticing dentistry  have  succeeded  in  completely  filling  the  canals  of  all 
cases  which  they  have  undertaken,  I  do  not  believe.  That  they  may 
believe  that  such  success  has  been  attained  I  do  not  doubt,  and 
therefore  I  accept  such  statements  as  honestly  intended,  but  erro- 
neous from  the  fact  that  the  gentlemen  have  not  considered  teeth 


BIE  THODS  OF  FILLING  CANALS  OF  PULPLESS  TEE  TH.     1 9 1 

except  as  they  have  dealt  with  them  in  the  mouths  of  patients,  under 
which  circumstances  failure  to  reach  the  apex  may  be  undistinguish- 
able.  A  study  of  roots,  out  of  the  mouth,  and  an  attempt  to  fill  the 
canals,  would  materially  alter  the  opinions  of  those  who  are  so 
certain  that  they  always  reach  the  apex.*  Nevertheless,  I  think  that 
these  men  get  nearer  to  the  ideal  root-filling  than  do  those  who  are 
willing  to  say  quickly,  "  That  is  as  far  as  I  dare  to  go,"  and  so  fill 
the  canal  without  having  made  a  conscientious  effort  to  cleanse  it.  I 
will  now  consider  the  canals  of  various  teeth. 

Central  Incisors. — The  superior  central  incisor  is  usually  a  single- 
rooted  tooth,  presenting  a  fairly  straight  canal.  Nevertheless,  it  must 
always  be  borne  in  mind  that  the  crown  of  a  tooth  is  not  necessarily 
a  guide  to  the  length,  shape,  or  direction  of  its  root.  More  true 
of  the  posterior  regions,  this  axiom  is  also  true  of  teeth  in  the  anterior 
part  of  the  jaw.  Fig.  20  r  represents  a  central  incisor  whose  crown 
and  root  are  about  proportionate,  whilst  in  Fig.  202  is  seen  another 


Fig.  201.        Fig.  202.        Fig.  203.      Fig.  204.      Fig.  205 


central  which  has  a  larger  crown  and  a  shorter  root.  Such  short, 
thick  roots  are  by  no  means  uncommon  on  central  incisors.  The 
point  of  interest  here  is,  that  supposing  the  dentist  is  cleansing  the 
canal  of  a  tooth  having  such  a  crown  as  shown  in  Fig.  202,  measure- 
ment with  a  canal  instrument  might  lead  him  to  believe  that  he  had 
not  reached  the  end  of  the  canal,  whereas  were  he  to  attempt  to  go 
farther  he  would  pass  through  the  apex,  forming  an  opening  at  the 
side  of  the  true  foramen.  I  think  it  may  be  safely  stated  that  in 
ninety  per  cent,  of  tooth-canals  there  is  a  deviation  from  a  straight 
line  just  in  the  foraminal  region,  so  that  a  drilling  instrument  would, 
as  I  have  said,  be  apt  to  pass  out  to  one  side  rather  than  directly 
through  the  foramen.  These  artificially  made  openings  are  almost 
always  mischievous,  and  the  mischief  is  greater  or  more  uncontrol- 
lable in  proportion  as  the  drill-hole  is  nearer  the  foramen  and  so 
more  inaccessible  than  were  it  nearer  the  coronal  end  of  the  canal. 
I  said  that  a  central  presents  a  fairly  straight  root  and  canal ;  still, 
there  are  frequent  cases  where  the  root  is  twisted  or  curved,  an 
example  of  which  is  shown  in  Fig.  203.  In  the  illustration  the 
palatal  aspect  of  a  central  is  given,  and  is  chosen  in  preference  to  the 


19-  METHODS  OF  FILLING   TEETH. 

labial,  because  of  the  line  of  approximate  bifurcation  seen  from  this 
view.  This  makes  it  possible  that  the  canal  within  may  be  divided, 
the  bifurcation  of  a  pulp  usually  being  coincident  with  that  form  of 
root.  This  figure  also  shows  a  distinct  curve  near  the  apex,  and 
exhibits  the  danger  that  would  accompany  the  free  use  of  any  style 
of  drill  that  has  a  point  allowing  it  to  make  forward  cutting. 

The  central  in  the  inferior  jaw  is  usually  found  with  a  broad,  flattened 
root,  which,  viewed  from  the  side,  presents  a  concaved  groove  extend- 
ing the  full  length  of  the  root.  This  groove  is  very  significant,  for  it 
is  the  lateral  wall  of  the  canal,  so  that  it  follows  that  the  pulp-canal  is 
the  narrowest  diameter  of  the  tooth.  We  must  also  note  that  these 
lateral  walls  are  quite  thin.  If  a  canal-reamer  were  used  which  had  a 
bur-head  larger  than  this  narrow  diameter  of  the  tooth,  it  would 
follow  of  necessity  that  this  lateral  wall  would  be  punctured,  so  that  it 
is  not  alone  the  forward  cutting  of  a  canal  instrument  which  ofifers  a 
danger  of  opening  through  the  roots  of  teeth.  It  would  rarely  if 
ever  be  necessary  to  use  a  drill  or  ream.er  in  the  lower  incisors,  because, 
as  seen  in  Fig.  204,  though  the  canal  is  flattened  laterally,  it  is  usually 
wide  enough  in  the  other  direction  to  afford  ample  space  for  cleansing 
and  subsequent  filling. 

Lateral  Incisors. — The  roots  of  superior  lateral  incisors  almost 
invariably  terminate  in  a  crook  at  the  apex  which  curves  posteriorly. 
In  Fig.  205  is  shown  a  curious  example.  Judging  by  the  general 
direction  of  the  crown,  the  course  of  the  root  could  not  be  guessed  at 
all.  The  root  curves  toward  the  median  line  of  the  mouth  at  a  con- 
siderable angle,  yet  at  the  apex  the  rule  above  stated  is  found  exempli- 
fied, there  being  a  crook  which  turns  posteriorly.  It  is  probable  that 
the  root  of  this  tooth  was  upright  when  in  the  alveolus,  the  crown 
appearing  irregularly  curved  toward  the  centrals.  Were  it  not  dis- 
covered that  this  curve  of  the  root  existed,  it  is  evident  that  were  the 
root  drilled,  the  instrument  might  emerge  someivhere  about  half-way 
between  the  crown  and  root-end. 

Fig.  206  shows  another  lateral  incisor,  where  we  find  a  crown  not 
much  larger  than  in  the  last  case,  whereas  the  root  is  much  longer. 
Again  is  seen  the  posterior  crook  at  the  extremity.  An  approximal 
view  of  this  root  would  show  also  an  apical  curve  toward  the  labial 
plate  of  the  alveolus. 

The  lateral  incisors  of  the  inferior  jaw  do  not  materially  differ  from 
the  centrals,  except  that  they  are  slightly  larger. 

Cuspids. — The  cuspid  is  usually  the  most  readily  filled  of  all  pulp- 
less  teeth.  Ordinarily  the  canals  are  proportionately  large  and 
moderately  straight,  and  one  feels  fairly  satisfied  that  at  least  in  this 
tooth  the  canal  may  be  filled  to  the  extremity.  Yet  take  a  handful  of 
cuspids,  and  an  examination  of  them  out  of  the  mouth  will  show  so 


A  STUDY  OF  TOOTH- ROOTS. 


193 


many  crooked  extremities,  or  ends  that  assume  twists  and  curves,  that 
a  doubt  is  engendered,  and  one  may  well  wonder  whether  even  here 
perfect  results  are  always  attained.  May  it  not  be  that  because  the 
canal-explorer  reports  that  considerable  length  of  canal  has  been 
reached,  the  operator  decides  that  he  must  have  come  to  the  apex? 
May  there  not  still  be  a  crook  beyond,  which  has  not  been  touched  by 
instruments,  however  fine?    Compare  Figs.  207  and  208.  In  both,  the 


Fig.  206. 


Fig.  207. 


Fig.  208. 


Fig.  209. 


Fig. 210. 


crowns  are  about  similar  in  size,  yet  how  different  the  length  of  root. 
In  Fig.  207  observe  the  crook  which  tips  the  root  end  almost  at  right 
angles.  Look  at  Fig.  209,  with  its  curved  root  and  crooked  end, 
and,  drawing  an  imaginary  line  through  the  central  axis  of  the  crown, 
note  where  it  would  emerge  through  the  side  of  the  root  were  a  drill 
to  follow  the  same  course.  Fig.  210  shows  a  double-rooted  cuspid, 
and  it  would  not  be  difficult  to  imagine  a  dentist  thoroughly  cleansing 
and  filling  the  labial  canal,  entirely  neglecting  the  palatal,  because  of 
its  small  size  and  rarity. 

Bicuspids. — The  first  superior  bicuspid  brings  us  many  problems  in 
root-filling.     Usually  the  canals  are  bifurcated,  whether  the  roots  are 


Fig.  2X2. 


Fig.  213. 


or  not.  Sometimes  the  canal  will  be  confluent  throughout,  being  con- 
nected by  a  narrow  passage,  as  shown  in  the  diagrammatic  section  in 
Fig.  211.  Here  a,  a  indicates  the  openings  to  the  canals  proper, 
whilst  at  b  is  seen  a  narrow  passage  connecting  the  two.  It  is  this, 
passage  which  is  a  point  of  great  interest.  It  is  almost  always  present, 
at  least  in  the  pulp-chamber  occupying  the  crown.  It  is  safe  to. 
enlarge  it,  thus  completely  connecting  the  two  parts  of  the   canal,, 

13 


194 


METHODS  OF  FILLING  TEETH. 


until  the  line  of  the  tooth-neck  is  reached.  Beyond  this  it  becomes 
necessary  to  observe  the  greatest  caution  in  proceeding,  in  order  to 
determine  how  far  such  enlargement  may  be  pursued,  whether  or  not 
the  canals  are  normally  connected  throughout,  or  whether  they  or  the 
roots  are  bifurcated.  In  Fig.  212  is  shown  a  first  bicuspid  wherein 
the  canals  are  probably  united  in  this  way  throughout,  as  I  judge  by 
holding  the  specimen  up  to  the  light  so  that  the  canals  are  indicated, 
and  by  the  further  fact  that  they  emerge  at  a  single  foramen.     Yet 


Fig.  214. 


Fig.  215. 


Fig.  216. 


Fig.  217. 


observe  the  curious  distortion  of  the  root,  and  it  is  plain  that  enlarge- 
ment within  the  canals  would  be  a  procedure  requiring  the  utmost 
care,  whilst  complete  root-filling  would  be  of  doubtful  possibility. 

Fig.  213  shows  us  the  palatal  aspect  of  a  bicuspid  in  which  there 
appears  a  bad  crook  in  the  palatal  root,  which  curve  is  present  in  the 
buccal  root  also,  though  in  a  less  marked  degree.  Fig.  214  shows 
the  buccal  aspect  of  a  bicuspid  which  has  a  similar  crook,  a  second 
curvature  appearing  nearer  to  the  apex.  Fig.  215  is  another  bicus- 
pid, the  curve  here  being  near  the  end  of  the  root  and  very  pro- 
nounced in  character.  In  any  of  these  three  teeth  a  root-canal  drill 
would  be  a  hazardous  dependence,  and  as  the  contours  of  root-canals 

Fig.  218.  Fig.  219.  Fig.  220.  Fig.  221. 


cannot  be  known  from  the  appearance  of  the  crowns,  it  becomes 
necessary  to  make  thorough  exploration  before  attempting  to  use 
any  engine  instrument,  especially  those  having  long  slender  shafts. 
Fig.  216  shows  a  tooth  the  roots  of  which  are  united,  a  deep  groove, 
however,  indicating  that  the  canals  may  be  distinct,  which  is  shown 
to  be  true  when  examined  by  transmitted  light. 

Fig.   217  is  of  the  same  class,  the  bifurcation  of  the  roots  in  the 
immediate  vicinity  of  the  foramen  being  more  distinct.       Fig.   218 


A  STUDY  OF  TOOTH-ROOTS. 


195 


gives  us  a  tooth  practically  similar  to  that  depicted  in  Fig.  216, 
Here,  however,  we  have  a  ground  section  which  brings  us  to  a 
clinical  feature  of  tremendous  importance.  A  portion  of  the  side  of 
the  tooth  has  been  removed  with  great  care,  so  that  no  portion  of  the 
canal  shall  be  obliterated,  the  stone  not  passing  beyond  the  center 
line.  The  pulp-chamber  is  clearly  seen,  as  well  as  the  bifurcation  of 
the  canals  in  what  externally  seems  to  be  a  single-rooted  tooth.  But 
in  the  vicinity  of  the  apex  the  track  of  the  canal  can  only  be  seen  by 
examining  with  a  magnifying  glass,  and  even  then  it  seems  to  be 
closed  as  though  ossified.  Of  course  it  is  not,  and  in  life  a  fine 
thread  of  living  pulp  passed  through  this  foramen.  But  this  passage 
is  so  fine  that  the  eye,  even  aided  with  a  magnifying  glass,  cannot 
discern  that  it  exists.  Moreover,  the  finest  canal  bristle  cannot  be 
made  to  penetrate  this  passage,  which,  though  open,  appears  closed. 
If  this  be  true  with  the  specimen  in  the  hand,  who  can  say  that  in  the 
mouth  he  would  have  been  able  not  only  to  explore  this,  but  to 
properly  fill  it  subsequently  ?     It  may  be  claimed  that  this  canal  could 


Fig.  222. 


Fig.  223. 


Fig.  224. 


Fig.  225. 


be  enlarged  with  chemical  agents.  That  will  be  discussed  later.  At 
this  point  we  may  simply  consider  it  a  barrier  impassable  to 
mechanical  devices,  yet  in  reality  a  true  open  passage.  Moreover, 
this  condition,  as  indicated  here  by  a  single  specimen,  is  not  rare. 
Indeed,  in  many  of  the  tortuous  canals  of  molars  this  fine,  impassable 
canal  is  far  from  uncommon.  This  should  not  be  disputed  by  anyone 
until  he  has  made  sections  of  at  least  a  hundred  twisted  or  con- 
stricted molar  roots.  That  such  tiny  passageways  may  contain  living 
matter  need  cause  no  one  to  wonder.  There  are  beetles  so  small  that 
the  entomological  collector  finds  them  by  using  the  finest  meshed 
sieve  and  sifting  out  a  handful  of  dirt,  the  beetles  remaining  with  the 
larger  debris,  but  not  to  be  found  until  the  collector  is  in  his  den  and 
seeks  them  with  a  magnifying  glass.  Yet  these  tiny  creatures  are 
highly  organized,  and  have  powerful  muscles  with  which  to  move 
their  limbs.  The  power  of  motion  is  transmitted  to  these  muscles 
by  nerve-fibers  so  small  that  a  dozen  of  them  twisted  into  a  rope 
could  occupy  one  of  our  invisible  root-canals. 

Fig.  219  brings  us  to  the  opposite  extreme.     Here  we  see  a  tooth 


196 


METHODS  OF  FILLING  TEETH. 


from  a  child.  The  foramen  is  wide  open,  the  root  not  yet  being  fully- 
formed.  In  Fig.  220  we  see  a  similar  tooth  ground  to  expose  the 
canal,  which  is  very  wide  throughout,  the  foramen  being  as  wide  as 
any  part.  Should  a  pulp  die  in  a  tooth  of  this  character,  great  skill 
is  requisite  in  filling  the  canal  to  avoid  having  any  of  the  root-filling 
extend  beyond  the  apex,  in  which  case  an  abscess  would  not  be  an 
improbable  sequence.  Fig.  221  is  introduced  to  show  that,  unlike 
the  laterals,  there  is  no  rule  which  applies  to  the  direction  of  the 
possibly  existent  crook.  Here  the  apex  curves  toward  the  buccal 
plate  of  the  process,  while  in  Fig.  215  the  curve  is  postero-approxi- 
mally  ;  in  Fig.  217  the  deflection  is  toward  the  palatal  side.  Fig.  221, 
though  single-rooted,    has  two  distinct   canals   and   two   foramina. 


Fig.  226.  Fig.  227.  Fig.  228.  Fig.  229. 


Fig.  230. 


The  buccal  canal  would  be  a  serious  problem  in  filling,  being  attenu- 
ated as  well  as  badly  curved. 

Allusion  has  been  made  (Fig.  211,  <^)  to  a  narrow  passage  which 
often  connects  the  true  canals  in  double-rooted  bicuspids.  Where 
this  exists  it  becomes  highly  important  to  be  able  to  decide  to  what 
depth  it  may  be  widened.  A  study  of  Figs.  222,  223,  224,  225,  226, 
and  227  will  indicate  the  varying  extent  to  which  bifurcated  canals 
may  be  connected  with  true  bifurcation  of  the  roots.  Fig.  228 
represents  a  root  the  crown  of  which  has  been  lost.  Here  we  have 
a  trifurcation  which  produces  three  canals,  and  it  is  evident  that  the 
two  smaller,  especially  the  crooked  one,  would  be  troublesome. 

The  perforation  of  a  bicuspid  canal,  at  the  point  of  bifurcation, 
with  resultant  hemorrhage  and  subsequent  complications,  may  always 
be  avoided,  if  the  operator  will  approach  every  canal  as  though 
certain  that  the  bifurcation  exists.  If  he  should  discover  later  that 
the  canals  are  confluent,  or  that  the  tooth  is  single-rooted,  at  least  he 
will  have  attained  his  result  without  accident.  If,  on  the  contrary, 
he  should  overlook  the  possibility  that  there  might  be  a  bifurcation 
very  near  the  crown  (as  in  Fig.  224),  he  will  some  day  discover  this 
fact  by  having  his  engine  bur  plunge  through  the  root  into  the 
alveolus  beyond,  with  more  or  less  disastrous  consequences. 

The  second  bicuspid  is  usually  single-rooted,  though   even  here 


A  STUDY  OF  TOOTH-ROOrS. 


197 


two  caaals  may  be  distinctly  existent.  Fig's.  229  and  230  indicate 
that  similar  crowns  may  have  roots  quite  dissimilar  as  to  shape  and 
length.  The  latter  has  a  tiny  but  distinct  right-angled  crook  at  the 
foramen. 

Figs.  231,  232,  233,  234,  235,  and  236  furnish  a  variety  of  supe- 
rior second  bicuspids  which,  at  a  glance,  teaches  that  the  crown  is  no 
index  to  the  length  or  shape  of  the  root.  The  crown  of  Fig.  231  is 
as  large  as  that  of  Fig.  235,  yet  the  roots  are  dissimilar.  One  is 
twice  as  long  as  the  other,  and  whereas  in  one  the  curvature  is  toward 
the  palate,  in  the  other  the  principal  deflection  is  toward  the  buccal 
plate.  Fig.  234  shows  us  the  largest  crown,  but  look  at  the  dispro- 
portionate root.  Fig.  233,  apparently  a  single  root,  has  two  canals, 
as  have  also  Figs.  235  and  236. 

Fig.  231.       Fig.  232.      Fig.  233.       Fig.  234.       Fig.  235.      Fig.  236. 


Inferior  bicuspids  are  often  difficult  because  of  the  length  and 
attenuation  of  their  roots.  I  do  not  mean  that  this  is  always  so,  yet 
Fig;  237,  with  its  small  crown  and  long,  narrow  root,  is  a  fair  ex- 
ample of  a  lower  bicuspid,  while  Fig.  238  adds  to  the  difficulties  of 
the  situation  by  possessing  an  extensive  crook. 


Fig.  237.         Fig.  238. 


Fig.  239. 


Fig.  240. 


Figs.  239  and  240  are  two  first  bicuspids  from  the  lower  jaw,  ex- 
tracted from  the  same  mouth.  They  are  beautiful  examples  of  an 
extreme  but  far  from  rare  type.  I  have  another  pair  showing  exactly 
similar  contours.  The  point  of  interest  here  is  that  the  obstacle  which 
would  interfere  with  the  proper  treatment  of  the  roots  lies  not  in  the 
roots  themselves,  which  in  these  specimens  are  very  simple,  but  is 
rather  due  to  what  I  may  term  the  pose  of  the  crown.     Teeth  of  this 


198  METHODS  OF  FILLING    TEETH. 

type  are  often  found,  apparently  crowded  out  of  the  arch,  and  pro- 
truding lingually.  Of  course  normally  shaped  teeth  are  occasionally 
crowded  out  of  alignment,  but  often  the  seeming  irregularity  is 
mainly  due  to  the  malposition  of  the  crown  in  relation  to  the  root. 

Supposing  that  these  teeth  were  in  the  mouth,  the  roots  occupying 
the  normal  upright  position  in  the  bony  socket,  but  the  crown  tipping 
toward  the  tongue,  it  is  evident  that  the  best  approach  to  the  pulp- 
canal,  if  access  was  necessary,  would  be  through  a  cavity  drilled  in 
the  buccal  face  of  the  tooth,  rather  than  through  the  masticating  sur- 
face as  is  customary.  Where  the  original  cavity  is  in  the  approximal 
surface,  it  is  often  better  not  to  enlarge  it,  as  would  be  the  course 
elsewhere,  cutting  through  the  masticating  surface,  but  rather  to  make 
a  small  aperture  in  the  buccal  face  of  the  tooth,  thus  entering  the 
canal  directly,  and  through  an  opening  more  readily  managed  than 
one  in  the  masticating  surface.  Of  course,  before  adopting  this 
method,  it  is  highly  essential  that  the  true  direction  of  the  root  be 
known,  but  this  is  not  difficult.  Observe  the  plane  of  the  buccal  sur- 
face of  the  tooth  (Fig.  239),  and  if  the  root  follows  the  direction  in- 
dicated by  the  crown,  then  there  should  be  a  pronounced  bulge  of 
bone  just  below  the  corner  of  the  mouth. 


Fig.  241. 


Fig.  242. 


Fig.  243.  Fig.  244. 


Fig.  245. 


Molars. — The  buccal  roots  of  the  superior  molars  present  probably 
the  most  difficult  problems  in  the  whole  range  of  root-canal  fillings. 
To  the  prominent  gentlemen  who  have  repeatedly  asserted  that  they 
can  fill  any  buccal  root,  I  offer  the  pair  exhibited  in  Fig.  241  for  study 
and  consideration.  To  these  same  gentlemen,  and  to  those  who  are 
sure  that  at  least  they  can  fill  the  palatal  root,  I  offer  Fig.  242.  Sup- 
posing for  an  instant  that  they  succeed  in  overcoming  the  obstacles 
offered  by  the  crook  at  the  end  of  each  of  these  roots,  I  would  still 
ask  how  to  fill  the  canal  of  the  concrescent  tooth  seen  attached  to  the 
palatal  root.  Lest  it  be  said  that  such  conditions  are"  quite  rare,  I 
introduce  Fig.  243,  wherein  the  buccal  roots  are  almost  identical  to 
those  in  Fig.  241. 

The  original  of  Fig.  242  was  a  specimen  which  I  had  never  seen 
in  the  mouth,  but  since  the  publication  of  the  first  edition  of  this 


A  STUDY  OF   TOOTH-ROOTS. 


199 


work  I  had  a  case  pass  through  my  hands  in  which  the  recollection 
of  this  anomaly  was  most  advantageous.  A  molar  came  to  me  in 
which  an  old  amalgam  filling  was  leaking,  and  recurrent  caries  had 
reached  the  pulp,  making  devitalization  necessary.  In  cleansing  the 
canals  I  was  surprised  to  find  that  my  bristle  penetrated  so  slightly 
into  the  palatal  root,  and  I  was  further  astonished  to  find  the  opening 
of  the  canal  so  near  the  margin  of  the  cavity,  when  I  suddenly  re- 
called Fig.  242.  Further  exploration  disclosed  the  fact  that  I  had  not 
yet  opened  into  the  true  palatal  canal,  which,  when  discovered,  was 
of  normal  extent  The  short  extra  canal  was  unquestionably  of  the 
nature  of  that  indicated  in  the  illustration. 

Fig.  244  is  from  a  most  remarkable  specimen.  One  of  the  buccal 
roots  has  become  fused  with  the  palatal.  The  figure  shows  the  an- 
tero-approximal  aspect  of  the  tooth,  and  the  canal  of  the  missing 


Fig.  246.  Fig.  247.        Fig.  248.        Fig.  249.         Fig.  250. 


buccal  root  terminates  in  a  foramen  at  the  side  of  the  palatal  root  just 
above  the  bifurcation.  The  posterior  buccal  root  is  present,  but  all 
that  portion  above  the  line  of  bifurcation  would  defy  all  effort  to 
cleanse  or  fill,  not  alone  because  of  its  tortuosity  and  attenuation,  but 
because  the  opacity,  as  seen  by  transmitted  light,  indicates  to  me  that 
it  has  one  of  those  invisible  impassable  root-canals  described  in  con- 
nection with  bicuspids, 

It  is  not  uncommon,  when  cleansing  the  canals  of  upper  molars,  to 
have  tKe  bristle  pass  'into  an  opening  apparently  just  at  the  bifurcation 
of  the  three  normal  roots.  Examination  of  specimens  out  of  the 
mouth  proves  that  a  fourth  root  in  this  situation  is  far  from  rare. 
Fig.  245  is  a  well-marked  case  of  this  character.  Once  the  anomaly 
is  recognized,  there  would  be  no  difficulty  with  such  a  root  as  this. 
But  many  would  feel  content  with  filling  three  canals,  and  seek  no 
other.  Suspicion  should  be  aroused  whenever  this  central  canal 
does  not  curve  toward  the  buccal  plate  of  the  process. 

Fig.  246  is  from  another  such  specimen,  one  of  the  normal  roots 
being  broken  off,  so  that  the  one  in  the  center  is  the  fourth  root  under 
discussion.  Fig.  247  is  from  still  another  specimen.  Fig.  248  be- 
longs to  the  same  class,  though  here  the  extra  root  is  fused  with  one 
of  the   buccal  roots,   which  consequently  has   two  canals  and  two 


200 


METHODS  OF  FILLING    TEETH. 


foramina.  Fig.  249  also  has  the  little  fourth  root,  while  the  crook  in  the 
palatal  root  warns  us  that  all  palatal  roots  are  not  necessarily  simple, 
a  fact  further  emphasized  by  Fig.  250.  Here  the  palatal  root  has  a 
magnificent  curve,  while  the  two  buccal  roots  are  united  at  their  apices, 
ending  in  one  foramen,  though  otherwise  distinct  throughout.  In 
Fig.  251  we  have  excessively  long  roots,  the  two  buccal  being  fused 
but  having  distinct  canals,  that  in  the  anterior,  and  therefore  least 
accessible,  being  tortuous.  Fig.  252,  with  its  curved  and  hooked 
buccal  roots,  one  being  of  the  broad,  thin  variety,  offers  an  alluring 
prospect  to  those  who  are  really  fond  of  hard  work.  Fig.  253  shows 
how  attenuated  a  long  buccal  root  may  be,  and  the  variation  in  the 
length  of  the  two  buccal  roots  indicates  how  certainly  we  may  know 
when  filling  roots  in  the  mouth  that  we  have  reached  the  ends,  espe- 
cially when  the  length  of  one  root  is  depended  upon  as  a  guide  to 
the  length  of  its  neighbor. 

In  the  lower  jaw  it  is  usually  the  anterior  molar  root  that  is  trouble- 
some. Ordinarily  we  expect  single  canals,  though  in  the  anterior 
root  the  canals  are  often  bifurcated.      In   Fig.   254   is    a   specimen 


Fig.  251.     Fig.  252.       Fig.  253. 


Fig.  254. 


Fig.  255. 


wherein  the  posterior  roots  are  completely  bifurcated,  one  oiTering  so 
bad  a  crook  that  it  would  have  been  quite  difficult  to  fill  it.  In  the 
anterior  root  two  distinct  canals  exist,  though  the  root  is  single. 
This  tooth  and  its  fellow,  which  is  exactly  similar  to  it,  I  removed 
from  the  mouth  of  a  negro  boy.  They  are  sixth-year  molars.  This 
tendency  to  complete  bifurcation  is  more  common  in  the  posterior 
root.  I  have  a  number  of  specimens  which  show  the  double  root 
posteriorly  and  the  single  root  anteriorly,  being  similar  in  general 
appearance  to  Fig.  254,  the  extra  root  in  all  being  at  the  posterior 
lingual  angle. 

In  Fig.  255,  however,  we  see  a  specimen  which  indicates  that  the 
lower  like  the  upper  may  have  an  additional  appendage  between  the 
normal  roots,  just  at  the  bifurcation.  In  this  instance  no  true  canal- 
appears  in  the  appendage,  but  in  other  instances  I  have  known  a  fila- 
ment of  the  pulp  to  dip  down  into  such  an  extra  root,  diminutive 
though  it  be. 


A  STUDY  OF   rOOTH-ROOTS.  20I 

The  wisdom-teeth  {denies  sapientiee)  are  so  commonly  misshapen 
that  it  is  easier  to  get  specimens  with  distorted  roots  than  with  regu- 
larly formed  ones.  They  are  also  so  generally  condemned  to  the  for- 
ceps that  root-filling  is  seldom  practiced.  Yet  occasionally  it  is  best 
to  make  the  effort  to  save  such  teeth,  and  I  may  be  pardoned  for 
introducing  one  or  two  illustrations,  that  the  student  may  get  an  idea 
of  what  he  may  have  to  contend  with. 

Fig.  256,  from  the  upper  jaw,  would  be  a  puzzle,  whilst  Fig.  257, 
also  an  upper  tooth,  would  be  equally  so,  with  its  three  roots  all 
curved,  the  palatal  one  forming  almost  a  bow.  Fig.  258  is  a  fair 
mate  to  it  from  the  lower  jaw,  whilst  Fig.  259  indicates  that  we  cannot 
always  be  sure  that  a  wisdom-tooth  is  short-rooted.  The  length  of 
the  roots  in  this  case  would  be  almost  as  great  an  obstacle  to  thorough 
cleansing  and  filling,  as  would  the  curve  of  the  preceding  specimen. 

Lest  it  be  argued  that  I  have  selected  extreme  cases  for  illustrating 
the  difficulties  to  be  contended  with  in  filling  roots,  I  must  here  reply 
to  such  a  proposition.      In  the  first  place,  such  conditions  are  not  very 


Fig.  256.  Fig.  257.  Fig.  258.  Fig.  259. 


unusual  or  difficult  to  find.  That  this  is  true  is  made  plain  by  the 
statement  that  the  specimens  used  here,  with  a  i^^fi  exceptions,  were 
obtained  through  the  kindness  of  Dr.  Hasbrouck,  who  allowed  me  to 
look  through  a  small  lot  of  teeth  extracted  in  his  office.  The  speci- 
mens were  selected  in  about  ten  minutes.  I  could  have  chosen  in 
many  instances  much  more  remarkable  distortions,  but  did  not  think 
it  necessary.  I  could  readily  have  enlarged  the  number  tenfold,  but 
that  also  would  have  been  of  no  advantage.  Of  wisdom-teeth  there 
was  the  greatest  assortment,  possibly  because  more  of  these  are  sacri- 
fied  than  any  other  one  tooth.  The  only  real  rarity  among  the  fore- 
going illustrations  is  the  two-rooted  cuspid.  Yet  I  once  remoA-ed 
such  a  tooth  from  a  young  lady,  and  on  the  same  day  extracted  a  first 
bicuspid  for  her  mother  which  had  three  roots  much  more  marked 
than  those  shown  in  Fig.  228. 

Again,  I  may  defend  this  exhibit  by  the  argument  that  we  cannot 
learn  to  anticipate  possible  difficulties  by  a  study  of  simple  conditions. 


202  METHODS  OF  FILLING   TEETH. 

It  is  only  by  an  appreciation  of  the  fact  that  the  roots  of  teeth  are  of 
all  manner  of  shapes,  and  that  the  crown  is  not  a  sure  indication  of 
what  we  may  meet  in  exploring  the  roots,  that  we  can  hope  to  exercise 
that  precaution  and  attain  that  skill  which  will  make  it  possible  for  us 
to  reach  that  point  where  we  can  even  fool  ourselves  into  the  belief 
that  we  are  filling  all  roots  to  the  apices.  Yet  it  is  essential  that,  how- 
ever great  the  obstacles  may  be,  we  should  endeavor  to  do  this  ;  and  I 
will  now  try  to  explain  the  best  modes  of  so  doing. 

Methods  of  Gaining  Access  to  and  Preparing  Root-Canals. 

Before  a  root-canal  can  be  properly  filled,  it  must  be  thoroughly 
cleansed  and  made  accessible  for  the  material  which  is  to  be  used. 
Admitting  that  many  conditions  might  occur,  as  has  been  indicated 
by  the  foregoing  illustrations,  where  it  would  be  impossible  or  most 
difficult  to  fill  some  canals,  it  yet  is  true  that  many  of  these  can  be 
approximately  well  cared  for  where  proper  methods  are  employed, 
and  patience  and  skill  are  brought  to  bear  upon  the  obstacles.  Con- 
versely, many  simple  canals  are  often  improperly  filled  through  lack 
of  skill  or  from  laziness.  The  first  object  is  to  attain  free  access  to 
the  canal. 

Central  Incisors. — The  central  incisor  having  ordinarily  a  straight 
canal,  usually  of  fairly  large  size,  should  offer  few  obstacles  to  proper 
treatment.  The  cavity  of  decay  must  occur  either  upon  one  approxi- 
mal  side,  upon  the  palatal,  or  upon  the  labial  surface.  Where  it  is 
upon  the  palatal,  the  canal  is  readily  entered  from  that  point.  When 
upon  the  labial,  unless  the  cavity  is  well  extended  toward  the  incisive 
edge,  so  that  it  is  not  difficult  to  get  directly  into  the  canal,  I  should 
make  a  new  opening  at  the  palatal  surface.  Where  the  approximal 
cavity  is  small,  I  should  do  the  same  ;  but  where  large,  a  simple 
extension  of  the  palatal  border  of  the  cavity  should  be  made  until  a 
nerve-canal  instrument  could  be  made  to  enter  the  canal  without 
bending. 

Thus  it  is  seen  that  I  advocate  entering  the  central  incisor  from  the 
palatal  surface.  This  would  also  be"  the  case  where  a  pulp  had  died 
from  traumatic  disturbance,  and,  no  cavity  being  present,  a  drill 
should  be  passed  in  at  the  point  indicated.  The  enamel  being  un- 
broken, and  therefore  resistant  to  the  drill,  it  is  well  with  a  small 
corundum  point  to  grind  off"  the  polished  surface,  after  which  the  drill 
will  cut  readily.  The  drill  should  be  sharp  and  small,  making  a  nar- 
row opening  to  the  pulp-chamber,  which  is  afterward  enlarged  with 
fissure-burs.  A  cone  bur  also  does  this  rapidly.  Fig.  260  is  dia- 
grammatic, and  indicates  the  relation  between  the  usual  opening  of 
this    character  and   the   pulp-canal.      Through  such   an  opening  it 


PREPARING  ROOT-CANALS. 


203 


Fig.  260. 


Fig.  261. 


/^ 


might  be  possible  to  pass  a  flexible  broach  and  remove  the  pulp, 
but  it  is  evident  that  to  attempt  to  fill  the  root  might  result  in  im- 
proper treatment  of  that  part  between  the  opening,  a,  and  the  end 
of  the  canal  at  b.  Consequently,  my 
custom  is  to  insert  a  sharp  rose  bur 
through  the  opening  as  far  as  the  wall 
of  the  canal,  and  then  bring  it  for- 
ward toward  b,  removing  the  part 
intervening.  Even  with  the  opening 
thus  enlarged,  ready  access  will  often 
be  impeded  because  of  the  angle  at  c, 
so  that  with  a  bur  I  effect  further  en- 
largement, till  the  canal,  fully  opened, 
appears  as  seen  in  Fig.  261.  Where 
these  canals  are  large  enough,  they 
need  no  further  reaming  than  at  the 
aperture ;  but  where  they  are  dis- 
torted, attenuated,  or  partly  stopped 
up  because  of  deposits  of  secondary 
dentine  along  the  walls,  I  use  the 
reamer  as  far  as  possible. 

As  the  subject  of  reaming  or  not  reaming  canals  is  one  which  is  much 
discussed  and  disputed,  and  as  seemingly  equal  authorities  will  most 
positively  adopt  one  side  to  the  entire  exclusion  of  the  other,  I  may 
as  well  here  take  up  this  point  and  give  my  own  views,  based  upon 
my  experience.  The  chief  objections  to  using  a  reamer  to  enlarge  a 
canal  throughout  are,  first,  the  danger  of  making  an  aperture  through 
the  side  of  the  root  or  near  its  apex  ;  secondly,  danger  of  crowding 
debris  forward,  so  that  even  where  it  does  not  pass  through  the  root, 
carrying  possible  infection  into  the  territory  beyond,  it  may  become 
packed  into  the  canal  itself,  limiting  further  progress,  and  so  after  all 
preventing  the  proper  drilling  or  filling  of  the  canal  ;  lastly,  the  drill 
may  be  broken  off  and  remain  in  the  root. 

The  advocates  of  reaming  all  canals  say  that  by  enlarging  they 
insure  better  filling,  and  that  in  teeth  where  pulps  have  been  long 
dead  the  canal-walls  are  probably  in  a  partly  softened  and  certainly 
septic  condition.  In  these  teeth  is  it  not  better  to  remove  this,  than 
to  endeavor  to  disinfect  or  to  sterilize  it  ? 

Extremists  are  not  good  teachers.  The  man  who  reams  out  every 
canal  to  its  apex  is  as  unworthy  of  a  followiyig  as  the  other  man  who 
can  fill  all  canals  without  having  a  reamer  in  his  office.  The  true 
method  is  to  have  a  good  assortment  of  reamers,  to  know  how,  when, 
and  where  to  use  them,  and  to  use  them  with  skill  and  caution 
that  will  assure  success.      I  hope  that  I  belong  to  this  last  class,  and 


204 


METHODS  OF  FILLING    TEETH. 


Fig.  262. 


Fig. 


at  least  I  shall  describe  my  methods  of  using  reamers  as  I  go  along, 
indicating  where  obstacles  are  to  be  met  and  how  to  avoid  them. 

I  have  been  asked,  ' '  Can  you  drill  around  a  curve  ?' '     The  answer 
is  that  it  can  be  done,  and  many  times  must  be  done. 

Suppose  that  I  am  using  a  reamer,  and  I  feel  a  resistant  spring  to 
my  instrument,  yet  do  not  strike  the  end  against  anything  that  would 
indicate  that  I  have  reached  the  region  of  the  foramen.     I  know  at 
once  that  the  canal  has  a  central  curve  in  it,  and  that  as  soon  as  the 
head  of  the  reamer  reaches  this  place,  the  curve  of  the  wall  diverting 
the  drill-head,  makes  a  tension  upon  the  flexible  shaft  so  that  I  get  a 
response  which  I  have  described  as  feeling  a  resistant  spring.     This 
is  always  a  danger  signal.     Force  the  instrument  a 
bit  farther,  and  the  shaft  will  snap,  breaking  off 
the  drill-head.     Worse  thau  this,  the  broken  piece 
will  be  at  such  an  angle  that  it  cannot  be  removed. 
This  is  made  plainer  by  Diagram  262,  where  the 
drill-head  is  seen  at  a,  in  a  position  that  makes  its 
removal  impossible  without  very  great  enlargement 
of  the  cavity.     Where  this  happens,   it  is  evident 
that  all  the  canal  beyond  must  remain 
unfilled.     Consequently,  as  soon  as  the 
springy  resistance  is  noticed  the  reamer 
must    be  removed.      If  a   small- sized 
Gates- Glidden  drill  has  been  used,  the 
largest  size  may  be  chosen  to  replace 
it.     This,  having  a  stouter  shaft,  may 
have  the  power   necessary  to  success- 
fully resist  the  tension  while  the  drill- 
head  cuts  away  the  bulging  wall  at  b. 
If  it  was  the  largest-size  drill  that  was 
in  use  in  the  first  instance,  it  must  be 
replaced  by  a  fissure-bur  of  small  size, 
with  which  the  upper  bulge  at  c  could 
be  removed,  after  which  the  large  Glid- 
den  drill  will  readily  remove   the  obstacle  at  b. 
This  accomplished  by  either  method,  the  drill  can 
be  advanced  as  far  as  d,  beyond  which  it  cannot 
be  carried.     The  canal  would   now  present  as  in 
Diagram  263.     During  this  work  there  will  be  the 
danger  already  noted  of  clogging  up  by  pushing 
forward  debris.     This  may  and  must  be  avoided. 
It  results  mainly  from  the  desire  to  work  too  rapidly,  which,   by 
throwing  back  a  great  amount  of  debris,  renders  it  difficult  to  with- 
draw the  drill.     It  is  compelled  to  cut  its  way  through,  and  so  leaves 


PREPARING  ROOT-CANALS.  205 

within  the  canal  some  of  the  chips,  which  at  the  next  entrance  of  the 
drill  are  pushed  forward  and  packed  into  the  extremity.  The  proper 
method  is  to  avoid  this,  first  by  frequently  withdrawing  the  drill, 
cutting  only  a  little  at  a  time,  and  secondly  by  using  a  cleanser  every 
time  the  drill  is  removed,  with  which  the  debris  is  easily  loosened  so 
that  it  is  withdrawn  or  may  be  blown  out  with  the  air  syringe.  The 
continued  use  of  a  drill  of  the  Gates-Glidden  type  cannot  open  a  hole 
by  forward  cutting,  since  it  has  a  safe  end.  It  could  make  an  aperture 
by  lateral  cutting,  however,  if  used  where  the  canal  has  flattened 
sides  and  thin  walls.  This  is  most  common  in  lower  incisors  and  in 
first  bicuspids,  so  that  these  canals  should  be  most  carefully  scrutinized 
before  the  risk  of  using  a  drill  is  taken.  Even  where  it  is  deemed 
safe  to  use  it,  by  every  precaution  we  should  be  upon  the  alert  to 
avoid  the  disaster.  The  patient  should  most  certainly  give  a  sign  of 
pain  before  the  opening  could  be  actually  formed,  for  the  heat  from 
the  friction  would  be  conveyed  through  the  thinning  wall,  causing  a 
response.  Thus  it  is  a  safe  rule  to  withdraw  a  drill  upon  the  slightest 
evidence  that  it  causes  pain. 

In  Diagram  263  we  have  the  canal  partly  prepared  ;  but  as  the 
curve  at  the  extremity  prevented  the  further  use  of  the  drill,  what 
are  we  to  do  ?  What  has  been  gained,  since  it  is  after  all  this  very 
part  of  the  root  which  we  should  most  certainly  fill  ?  The  reply  is, 
first,  we  have  lost  nothing,  for  if  it  were  possible,  as  some  claim,  to 
fill  this  curved  part  without  enlargement  of  the  rest  of  the  canal,  we, 
assuredly  can  do  so  now,  with  greater  access.  In  fact,  we  can  more 
certainly  accomplish  it.  The  use  of  broaches  will  indicate  the  nature 
of  the  curve,  for  as  it  is  withdrawn  now,  the  curve  at  its  extremity, 
where  it  followed  the  bend  of  the  root,  will  not  be  bent  back,  the  en- 
larged canal  allowing  it  to  be  freely  removed. 

Lateral  Incisors. — Lateral  incisors  are  practically  the  same  as  cen- 
trals. They  are,  however,  smaller,  require  smaller  instruments  and 
greater  care,  and  are  more  often  found  with  a  curved  apex.  A  seem- 
ingly straight  canal  in  this  tooth,  therefore,  is  to  be  accepted  with 
greater  doubt  than  where  dealing  with  the  central. 

Ctcspids. — The  same  rules  apply  to  cuspids  as  to  the  incisors. 
Whilst  it  is  true  that  these  are  sometimes  short-rooted  teeth,  ordi- 
narily they  have  quite  long  roots,  so  that  the  dentist  must  make  a 
careful  examination  when  his  canal  explorers  pass  but  a  short  dis- 
tance into  the  canal  of  a  tooth  having  a  large  crown.  Where  the 
root  is  really  short,  the  canal  is  usually  large,  the  root  being  thick. 
Thus  it  will  not  be  difficult  to  determine  that  an  abnormal  condition 
is  at  hand.  There  Is  not  often  much  danger  of  penetrating  this  root 
with  a  Gates-Glidden  drill,  but  the  end  may  sometimes  be  suddenly 
attenuated,  which  will  also  be  the  case  in  the  canal,  so  that  the  drill 


2o6  METHODS  OF  FILLING   TEETli. 

may  seem  to  be  stopped  by  the  apex  of  the  root,  whereas  in  reality  it 
is  simply  that  the  canal  hag  suddenly  grown  so  much  smaller  that  the 
tip  of  the  drill  will  not  enter  it  sufficiently  to  allow  the  blades  behind 
it  an  opportunity  to  cut  and  so  enlarge  it.  An  examination,  how- 
ever, with  a  fine  instrument  after  the  careful  removal  of  debris  will 
disclose  the  fact  that  the  canal  continues  farther. 

Bicuspids. — Generally  the  bicuspids  may  be  opened  for  access  to 
the  canal  either  by  deepening  the  crown  cavity,  or,  where  it  is 
approximal  decay  which  is  present,  an  extension  into  the  sulcus 
attains  the  desired  end.  In  lower  teeth,  however,  this  is  sometimes 
troublesome,  as  will  be  more  fully  explained  shortly.  Where  in 
the  upper  jaw  the  cavity  is  at  the  neck  of  the  tooth,  a  new  entrance 
to  the  canal  should  be  made  by  entering  at  the  sulcus.  Where  a 
tooth,  well  filled  with  gold  approximally,  presents  needing  to  have 
a  canal  opened,  it  will  be  unwise  to  remove  the  filling,  as  to  drill 
through  the  crown  will  serve  the  purpose  adequately  and  save  refilling 
a  difficult  cavity. 

In  the  first  bicuspid  all  the  peculiarities  of  form  are  to  be  borne 
constantly  in  mind,  and  procedure  should  be  slow  and  careful. 
Partial  cleansing  may  disclose  the  fact  that  the  coronal  end  of  the 
canal  is  as  represented  in  Fig.  211.  The  next  point  will  be  to 
determine  just  how  deep  the  communicating  passage  b  extends,  and 
therefore  how  far  it  will  be  safe  to  attempt  thorough  connection  of  the 
two  canals,  for  as  two  canals  they  should  always  be  treated  at  the 
outset.  In  a  few  cases  it  will  be  possible  to  unite  them  throughout. 
Most  often  it  will  be  safe  to  use  a  rose  bur  freely  as  far  as  the  neck 
of  the  tooth.  Beyond  that  explorations  should  be  made  with  fine 
broaches,  passed  up  one  canal  and  then  forced  across  into  the  other, 
where  the  passage  exists.  This  will  prove  a  guide,  but  stiff'-shanked 
burs  must  be  discarded  for  working  farther  up  in  the  canals,  a 
slender  Glidden  drill  serving  better,  because,  whilst  resistant  enough 
to  clear  out  and  enlarge  any  passage  which  may  exist,  it  will  be  found 
difficult  with  such  a  tool  to  cut  through  solid  material.  Where  the 
rose  bur  or  fissure-bur  is  recklessly  used  for  this  place,  the  inevitable 
result  will  be  that  sooner  or  later  the  dentist  will  make  an  opening 
near  the  beginning  of  the  bifurcation  of  a  double-rooted  tooth,  or 
even  in  one  that  has  only  bifurcation  of  the  canals,  the  roots  being 
coalescent,  as  in  Fig.  216.  The  palatal  canal  will  not  be  so  difficult 
to  cleanse  as  the  labial,  and  in  this  latter,  drills  are  to  be  used  with 
the  utmost  caution  if  employed  at  all.  The  position  of  the  patient 
and  the  pose  of  the  tooth  will  generally  be  such  that  in  forcing  the 
drill  into  the  labial  canal  it  will  necessarily  bend,  and  to  revolve  a 
slender  steel  shank  under  such  circumstances  is  to  invite  a  fracture 

On  the  other  hand,  the  drill  will  be  more  easily  used  after  the  coronal 


PREPARING  ROOT-CANALS. 


207 


end  of  the  canal  has  been  thoroughly  enlarged,  for  the  reason  that, 
having  more  space  in  which  "to  play,"  it  will  be  less  likely  to  bend. 
Sometimes  the  cavity  in  the  crown  itself  may  be  enlarged,  so  that  the 
drill  will  more  directly  enter  the  canal.  When  this  can,  it  should  be 
done.  The  treatment  of  curved  extremities  is  the  same  as  with  the 
anterior  teeth. 

The  second  bicuspid  in  the  superior  jaw  is  usually  a  single-rooted 
tooth.  Nevertheless,  here  also  the  coronal  opening  will  frequently 
be  as  in  Fig.  211,  and  once  more  the  narrow  connecting  passage  at 
b  becomes  a  point  for  study.  This  root,  though  single,  is  generally 
broad  and  flattened,  and  viewed  out  of  the  mouth  often  has  the  pecu- 
liarity attributed  to  lower  incisors,  there  being  a  depressed  groove 
corresponding  with  the  center  of  the  inner  canal.  Thus  it  is  seen 
that  throughout  the  canal  the  walls  on  either  side,  corresponding  with 
b  in  the  diagram,  are  the  thinnest  part  of  the  tooth.  I  unite  the  two 
broader  parts  of  the  canal  in  a  somewhat  peculiar  way.  I  use  the 
Glidden  drills  as  though  there  were  two  canals,  exchanging  to  larger 
and  larger  drills  until  the  two  sides  are  as  thoroughly  cleansed  as 
possible.  This  done,  I  take  the  smallest  of  the  Glidden  set,  and, 
beginning  at  the  coronal  extremity  of  the  canal,  I  pass  the  drill 
from  one  side  of  the  canal  through  the  narrow  passage  to  the  other. 
This  is  carefully  repeated,  passing  higher  and  higher  up  the  extent  of 
the  canal,  until  I  either  clear  it  throughout  or  else  receive  some  inti- 
mation that  it  would  be  unwise  to  proceed  further, — for  it  must  never 
be  forgotten  that  this  tooth  also  may  be  bifurcated,  at  least  near  the 
extremity.  The  least  signal  of  pain  from  the  patient  makes  it  wise  to 
stop  work. 

The  lower  bicuspids  are  often  peculiarly  difficult  because  they  may 
be  in  some  abnormal  position,  the  most  common  and  troublesome  of 
which  is  a  tipping  inward,  so  that  the  labial  surface  is  really  partly 
occluding  with  the  upper  teeth.  It  is  plain  that  in  such  a  pose  nothing 
would  be  gained  by  opening  through  the  crown  with  the  hope  of  using 
a  Glidden  drill.  Where  the  cavity  is  in  an  approximal  surface,  however, 
such  extension  is  often  necessary  even  for  the  use  of  a  broach,  and 
occasionally  the  Pettit  reamer  may  be  used  to  advantage.  Where  the 
cavity  is  approximal,  but  near  the  gum  only,  or  where  it  is  similarly 
situated  at  the  labial  side,  extension  must  be  made  along  the  posterior 
approximal  angle  toward,  but  not  necessarily  into,  the  crown. 

Molars. — Superior  molars  having  approximal  cavities  are  made 
accessible  by  cutting  through  to  the  crown.  When  the  cavity  occurs 
elsewhere,  but  not  in  the  masticating  surface,  the  canals  are  to  be 
reached  not  through  the  original  cavity,  but  through  a  special  open- 
ing through  the  crown  made  for  the  purpose.  The  thorough  opening 
of  a  pulp-chamber  will  often    require  the  sacrifice  of  considerable 


2o8 


METHODS  OF  FILLING    TEETH. 


Fig.  264. 


Fig.  265. 


tooth-substance  ;  but  this,  though  a  pity,  is  unavoidable.  No  senti- 
mental ideas  should  tempt  the  dentist  to  hesitate  to  make  the  opening 
complete.  Where  the  original  cavity  is  at  the  posterior  approximal 
surface,  some  difficulty  will  be  met  in  cutting  through  the  crown  far 
enough  to  gain  access  to  the  anterior  buccal  root.  The  easiest  method, 
and  one  which  will  save  much  distress  to  the  patient,  as  well  as  time 
and  labor  for  the  operator,  is  as  follows  :  With  a  sharp  spear-drill,  drill 
a  hole  straight  to  the  pulp-chamber  through  the  anterior  sulcus.  The 
condition  at  this  point  is  shown  diagrammatically  at  Fig.  264,  which 
is  a  section  through  a  molar  showing  the  buccal  roots.  The  approx- 
imal cavity  and  pulp-exposure  are  seen  at  (2,  and  the  new- drilled  hole 
at  b.  The  next  step  is  to  insert  a  sharp  fissure-bur  in  this  hole  at  b, 
when,  using  ^  as  a  fulcrum,  and  slowly  tipping  the  instrument  as  it 
cuts,  a  passage  is  made  through  the  crown  with  comparative  ease. 
It  must  be  observed  here  that  we  have  two  advantages  by  this  method. 
First,  by  cutting  from  below  upward,  the  enamel  is  approached  from 
the  dentinal  side,  which  is  always  easier  than  to  attempt  to  cut  enamel 

from  its  outer 
surface.  Second, 
by  using  the 
point  c  as  a  ful- 
crum much  less 
force  need  be  ex- 
erted, and  that, 
having  a  ten- 
dency to  lift  the 

tooth  from  its  socket,  is  less  painful  than 
the  reverse  would  be.  Moreover,  there  is 
less  danger  of  having  the  tool  slip  when 
cutting  in  a  hole,  than  when  the  effort  is 
made  to  cut  from  the  approximal  surface 
directly  through  the  crown. 

This  groove  being  cut,  the  presentment 
from  the  coronal  aspect  is  as  shown  in 
Fig.  265.  The  next  step  is  to  choose  a 
large  rose  bur,  and,  passing  it  in  at  the 
posterior  opening  a,  bring  it  forward,  cut- 
■  ting  away  the  dentine  at  both  sides  freely, 
.  thus  undermining  the  enamel,  which  latter 
may  then  be  removed  with  a  chisel.  To 
those  who  have  not  essayed  this  method 
a  close  study  of  the  different  steps  is  advised,  for  by  it  otherwise  diffi- 
cult and  extensive  removals  of  very  dense  tooth-structure  are  made 
moderately  easy. 


«- 


METHODS  OF  CLEANSING  ROOT-CANALS. 


209 


Where  the  cavity  is  at  the  anterior  approximal  surface,  the 
pulp-chamber  must  be  entered  with  large  rose  burs,  and  then,  using 
the  anterior  adjacent  tooth  as  the  fulcrum,  the  procedure  is  much 
the  same  as  before,  the  enamel  being  undermined  from  the  dentinal 
side,  and  then  cut  away  with  chisels. 

Practically  the  same  rules  hold  with  the  lower  molars.  Here,  as 
is  often  the  case  where  the  pulp  is  exposed  at  the  buccal  cavity,  a 
drill-hole  is  made  as  before  in  the  anterior  end  of  the  sulcus  until  the 
chamber  is  entered,  after  which  the  entire  procedure  is  as  though 
there  were  no  buccal  cavity,  except  where  the  latter  is  so  large  that 
it  is  necessary  to  unite  it  with  the  new  crown  cavity. 

Methods  of  Cleansing  Root-Canals. 

Ready  access  having  been  obtained,  the  next  step  is  to  thoroughly 
cleanse  the  pulp-canals.     A  description  of  methods  which  are  ser- 
viceable in  the  most  intricate  cases  will  sufficiently 
indicate   the    line   of   procedure    in   less    difficult   Fig.  266.  Fig.  267. 
situations. 

The  great  prerequisite  is  the  Donaldson  canal- 
cleanser,  Figs.  266  and  267.  This  instrument 
radically  differs  from  what  is  commonly  known  as 
a  "nerve-broach."  The  latter  was  primarily 
intended  for  the  removal  of  pulps,  and  is  of  little 
if  any  service  for  other  purposes.  On  the  contrary, 
while  the  Donaldson  instrument  may  be  utilized  for 
removal  of  pulps,  its  chief  value  is  in  cleansing 
canals,  especially  the  attenuated  canals  in  tortuous 
roots  of  molars.  An  examination  of  Fig.  266,  in 
which  the  instrument  is  shown  magnified,  will  dis-. 
close  the  fact  that  the  barbing  of  the  wire  is  quite 
different  from  ordinary  broaches.  In  the  old  style 
broach,  the  barb  was  cut  resembling  the  barb  of  a  fish-hook,  being 
a  long,' slender,  sharp  point.  Rotation  or  twist  closes  the  barbs, 
injuring  the  instrument  so  that  it  is  never  as  perfect  after  use  as  when 
new.  The  Donaldson  cleanser  is  differently  constructed  ;  the  wire 
is  round,  and  the  barbs  cut  to  a  slight  depth,  only  turning  up  what 
may  be  likened  to  a  round-edged  hoe  ;  moreover,  these  barbs  are 
rigid,  and  can  neither  be  twisted  nor  bent  back  to  place  against  the 
shaft.  Besides,  the  wire  is  barbed  on  all  sides  so  that,  being  ar- 
ranged spirally  around  the  shaft,  the  instrument  may  be  carefully 
screwed  into  a  canal,  and  then,  being  withdrawn,  the  hoe-shaped 
blades  or  barbs  act  as  scrapers  and  cleanse  the  canal  on  all  sides. 

Of  equal  or  even  greater  service  is  the  Donaldson  bristle,  unbarbed. 
This  is  made  of  piano-wire  drawn  fine,  and  may  be  forced  into  very 

14 


2IO 


METHODS  OF  FILLING    TEETH. 


Fig 


attenuated  and  tortuous   canals.      In  fact   I   may  erect  the  dogma, 
"Where  the  Donaldson  bristle  will  not  penetrate,   no  root-filling  is 

required. ' '  These  unbarbed 
bristles  are  to  be  used  with 
the  preparation  of  Sodium 
and  Potassium.  This  is  fiir- 
nished  in  small  tube-like  bot- 
tles, the  mixture  resembling 
a  soft  amalgam,  and  being 
covered  with  a  solid  layer  of 
paraffine.  To  reach  the 
mixture  an  .instrument  is 
carefully  passed  ^through  the 
paraffine,  thus  forming  a 
small  hole  through  which  the 
bristle  may  be  plunged  into 
the  Sodium  and  Potassium 
mixture.  The  bristle  should 
be  thoroughly  roughened  by 
running  a  coarse  corundum 
over  its  surface,  after  which 
it  will  readily  take  up  the 
right  proportion  of  the  So- 
dium and  Potassium  mixture 
to  be  used  in  the  canal. 

The  rubber-dam  being  in 
position  and  free  access  to 
the  canals  having  been  ob- 
Itained,  let  us  suppose  that 
the  buccal  canals  of  an  upper 
molar  prove  to  be  so  minute 
that  the  bristle  scarcely  dis- 
covers the  openings.  A 
minute  three-cornered  ream- 
er, made  from  a  broken 
Gates-Glidden  drill,  is  placed 
in  the  right- angle  hand- 
piece and  the  engine  re- 
volved rapidly.  The  point 
of  the  reamer  is  then  gently  insinuated  into  the  mouth  of  the  canal, 
very  little  pressure  being  used.  Frequently  this  hair-like  reamer  will 
open  quite  a  passageway,  but  it  must  be  thoroughly  understood  that 
it  is  not  wise  to  attempt  to  reach  far  into  the  root  with  this  delicate, 
easily-broken  instrument.     The  object  is  merely  to  open  up  as  far  as 


METHODS  OF  CLEANSING  ROOT-CANALS  21 1 

may  be  done  in  perfect  safety,  and  this  will  almost  invariably  be  suf- 
ficient for  further  progress  with  the  bristle.  The  reamer  is  then  laid 
aside  and  as  large  a  bristle  as  can  be  used  is  selected,  and  it  should 
be  short  and  stout  enough  to  withstand  considerable  pressure.  The 
bristle,  roughened  with  the  corundum  as  before  described,  is  dipped 
into  the  Sodium  and  Potassium  preparation,  and  coated  with  this 
valuable  agent  is  passed  into  the  canal  and  twisted  slowly  and  firmly 
toward  the  end.  This  repeated  once  or  twice  will  gain  some  head- 
way, whereupon  the  canal  should  be  thoroughly  washed  out  with  a 
one  to  five  hundred  solution  of  bichloride  of  mercury  in  hydrogen 
peroxide,  used  in  a  powerful  syringe  having  a  gold  or  platinum 
needle,  Fig.  268.  Frequently  (especially  in  the  presence  of  septic 
pulp-tissue)  this  forcible  injection  will  extrude  stringy  masses  re- 
sembling soft  soap.  All  such  debris  having  been  washed  out,  a 
smaller  bristle  is  selected  and  the  same  method  repeated,  and  this 
process  is  pursued  until  the  operator  is  convinced  that  further  advance 
toward  the  apex  is  impossible,  or  until  the  foramen  is  reached,  which 
will  be  no  uncommon  result. 

It  is  undoubtedly  true  that  many  root- canals  are  so  minute,  or  so 
obliterated,  that  neither  mechanical  methods  nor  chemical  agents 
make  it  possible  to  reach  the  apex  {vide  illustrations  and  previous 
text).  Fortunately,  if  such  canals  are  cleansed  as  far  as  possible, 
using  the  word  possible  in  its  most  rigid  sense,  there  will  seldom  be 
reason  for  mental  anxiety  as  to  the  future  health  of  the  tooth.  On 
the  other  hand,  unfortunately,  the  fact  that  there  are  roots  which 
cannot  be  explored  to  their  foramina  is  utilized  by  many  as  a  balm  to 
the  conscience  when  roots  are  neglected  which  another  more  con- 
scienfious  or. more  skillful  man  could  cleanse  and  fill  from  apex  to 
crown. 

A  case  from  practice  may  be  cited,  as  instructive  of  what  is  the  final 
possibility  in  root-canal  cleansing  and  what  the  limit  which  even  skill- 
ful men  place  upon  their  capabilities.  A  patient  placed  himself  in  my 
care  for  the  treatment  of  a  lower  molar,  which  he  said  had  been 
"treated  and  filled  seven  times,  and  has  never  been  comfortable." 
There  was  no  history  of  abscess  ;  no  one  of  the  seven  dentists  had 
discovered  pus  ;  but  all  had  unfilled  the  tooth,  undoing  the  prede- 
cessor's work,  unfiUing  and  refilling  the  roots.  I  did  likewise,  re- 
moving a  large,  handsome  gold  filling  from  the  crown,  a  substantial 
layer  of  oxyphosphate  from  below,  and  finally  gutta-percha  from 
anterior  and  posterior  canals.  In  these  two  canals  the  root-fillings 
were  easily  removed  because  the  depth  was  inconsiderable,  the  bottoms 
of  the  canals,  as  far  as  they  had  been  opened,  being  discernible  to  the 
eye.  To  relate  what  I  did  in  detail  would  be  but  a  reiteration  of  the 
above-described  processes.     I  will  only  state  that  I  gave  that  tooth 


212  METHODS  OF  FILLING    TEETH. 

four  hours'  treatment,  but  I  reached  the  apices  of  four  canals,  as  was 
convincingly  proven  by  the  fact  that  pus  rose  in  each.  The  time 
mentioned  was  not  occupied  at  a  single  sitting,  four  visits  having 
been  made  before  all  the  canals  were  thoroughly  cleansed.  This 
abscess  without  fistula  having  been  thus  discovered,  and  the  canals 
being  fully  cleansed,  the  disease  was  readily  cured  by  antiseptic 
measures  and  the  tooth  refilled.  Aside  from  pecuniary  recompense 
in  such  a  case,  there  is  full  compensation  in  the  consciousness  of 
having  passed  beyond  the  limit  of  procedure  set  up  by  several  gentle- 
men of  skill,  and  such  a  success  is  an  incentive  and  a  spur  when 
treating  other  roots  which  at  first  seem  to  be  inaccessible. 

When  and  How  to  Fill  Root-Canals, 

In  discussing  the  actual  filling  of  root-canals,  it  is  essential  to  con- 
sider, at  one  and  the  same  time,  the  condition  of  the  tooth  and  the 
method  of  filling  its  canal ;  for  despite  the  fact  that  many  skilled  opera- 
tors have  but  a  single  method  of  treating  all  roots,  I  deem  it  wiser  to 
be  guided  somewhat  by  the  state  of  health  presented. 

Before  proceeding,  however,  I  will  allude  to  some  of  the  various 
materials  which  have  been  largely  recommended,  and  comment  upon 
them. 

Gold. — Gold  at  one  time  was  counted  the  only  true  material  for 
fining  a  canal.  If  the  tooth  needed  gold  in  the  cavity,  it  also  needed 
this  precious  metal  in  the  root.  The  method  adopted  was  to  twist  a 
rope  of  foil  stiff  enough  to  allow  of  its  being  forced  into  the  canal, 
and  yet  soft  enough  so  that  it  could  be  condensed  thereafter.  The 
method  condemns  itself,  for  it  is  apparent  with  but  a  moment' s,  con- 
sideration that  wherever  the  foramen  was  large  the  rope  would  be 
forced  through,  with  the  probability  of  causing  future  irritation  and 
abscess.  This  is  true  of  other  materials,  but  in  a  less  degree  because 
of  their  plasticity.  Lest  some  may  claim  that  I  am  exaggerating  this 
danger,  I  may  say  that  I  have  frequently,  in  earlier  years  of  practice, 
removed  abscessed  roots,  finding  gold  projecting  beyond  the  foramina. 

Lead. — Lead  has  been  used  considerably,  and  by  some  it  is  claimed 
that  it  exerts  a  therapeutic  effect.  Just  how  this  is  accomplished  has 
never  been  satisfactorily  explained  to  me,  and  I  doubt  its  truth.  It  is 
used  in  a  single  cone,  trimmed  to  shape  with  the  knife,  and  driven  into 
the  root.  The  same  accident  of  passing  through  the  canal  may  occur, 
and  again  it  may  be  wedged  into  the  upper  part  of  the  canal  without 
reaching  and  filling  the  foraminal  end. 

Wood. — Within  recent  years  it  has  been  taught  by  some  that  a 
most  excellent  way  of  filling  a  root- canal  is  to  trim  the  end  of  a  stick 
of  orange  or  other  wood,  and  after  dipping  it  into  some  germicide 


FILLING   OF  ROOT-CANALS.  213 

drive  it  into  the  canal,  leaving  it  there.  I  cannot  too  strongly  con- 
demn this  method.  Once  more  we  find  the  material  driven  through 
the  canal  end  ;  and  even  where  this  does  not  happen,  abscesses  are 
common.  I  have  seen  a  very  large  number  of  them.  Then,  when 
it  is  imperative  to  remove  the  canal-filling,  the  operation  will  prove 
most  trying.  The  wood  splinters,  so  that  it  cannot  be  withdrawn 
with  forceps,  tweezers,  or  pliers,  whilst  a  drill  simply  tears  it  to  shreds 
which  are  still  more  difficult  of  removal. 

Cotton. — Next  to  wood,  I  think  this  the  most  despicable  thing  to 
leave  permanently  within  a  tooth-root.  I  have  heard  men  tell  of 
removing  cotton  which  had  been  in  teeth  for  many  years,  and  which 
had  kept  the  canals  sweet,  there  being  a  noticeable  odor  of  carbolic 
acid  still  present.  I  always  think  that  the  odor  is  probably  due  to  the 
fact  that  the  dentist  uses  that  remedy  freely,  so  that  he  can  smell  it 
whenever  his  own  fingers  get  near  to  his  nostrils.  I  have  removed  a 
great  many  cotton  root-fillings,  and  have  noticed  distinct  odors  in 
nearly  all  cases,  but  they  have  been  far  from  sweet.  They  have  been 
of  that  order  which  is  associated  with  the  dead  and  the  putrescent.  In 
some  cases  I  have  unearthed  odors  which  were  as  vile  as  anything 
that  had  ever  assailed  my  olfactories.  I  will  introduce  here  a  case 
from  the  practice  of  a  dental  friend  which  is  instructive  and  suggest- 
ive. A  physician  called  upon  him,  bringing  his  wife,  concerning  whose 
condition  the  dentist  was  consulted.  The  history  was  that  at  each 
menstrual  period  the  woman  sufifered  greatly  with  neuralgic  pains  in 
the  uterine  region.  These  increased  in  severity,  and  after  a  time 
occurred  as  well  in  the  face.  This  latter  fact,  coupled  with  the  time 
at  which  the  symptoms  had  first  presented,  which  was  directly  after 
having  a  large  amount  of  dentistry  done,  suggested  to  the  mind  of  the 
husband  that  possibly  the  teeth  might  be  the  distant  cause  of  all  the 
trouble.  My  friend  made  an  examination,  and  finding  both  central 
incisors  pulpless,  hazarded  the  removal  of  gold  fillings,  when  he  dis- 
covered that  the  roots  were  filled  with  cotton.  This  was  removed,  and 
after  sterilization  they  were  filled  wath  gutta-percha,  and  the  cavities 
as  before  with  gold.  For  six  months  the  neuralgic  pains  occurred, 
only  in  much  less  severe  shocks.  As  there  was  some  improvement, 
the  husband  was  encouraged,  but  decided  that  there  might  be  other 
teeth  in  similar  condition,  and  insisted  upon  the  removal  of  all  the 
fillings  under  which  there  was  even  a  remote  possibility  of  finding 
cotton.  This  resulted  in  such  a  discovery  in  three  more  teeth,  and 
after  proper  treatment  the  patient  was  entirely  restored  to  health. 
Never  fill  a  root  permanently  with  cotton. 

Cements. — The  cements,  so  called,  including  oxy chloride  and  oxy- 
phosphate,  must  of  course  be  relied  upon  in  setting  crowns,  and 
therefore  if  they  serve  in  those  cases  it  follows  that  they  must  be 


214  METHODS  OF  FILLING    TEETH. 

reliable  in  any.  This,  however,  must  be  modified,  for  where  a  crowrs 
is  set,  the  canal  is  usually  enlarged  so  considerably  that  the  cement 
is  readily  carried  to  all  parts  of  the  root.  Where  the  natural  crown 
is  still  in  place,  it  might  not  always  be  possible  to  thoroughly  fill  the  canal 
with  such  a  plastic  material.  Some  claim  that  oxyphosphate  lacks 
the  virtues  of  oxychloride,  but  the  statement,  however  authoritatively 
asserted,  would  be  hard  to  prove.  There  is  one  objection  to  either 
which  is  important.  It  is  difficult  to  remove  them,  should  it  be  desir- 
able to  empty  the  canal. 

Gutta-Percha. — This  material,  in  some  form,  is  used  by  the  majority 
of  dentists,  and  rightfully  so.  The  usual  custom  is  to  roll  the  white 
variety  into  cones,  which  are  slightly  warmed  and  pressed  into  the 
canal.  Chloro-percha  is  most  useful  when  not  relied  upon  alone. 
Forced  into  a  canal  and  followed  with  a  cone,  it  renders  the  operation 
of  filling  oftentimes  more  easy  and  more  perfect. 

The  form  of  gutta-percha  which  I  prefer  for  root-filling  is  Gilbert's 
temporary  stopping  ;  it  is  more  readily  made  into  cones,  more  easily 
softened  by  heat,  and,  in  case  of  future  necessity,  more  easily  re- 
moved. My  method  of  filling  root-canals  is  as  follows,  and  I  may 
state  that  a  perfect  root- filling  is  possible  wherever  the  Donaldson 
cleanser  can  be  passed  :  Supposing  that  the  tooth  has  been  rendered 
healthy  and  aseptic,  the  canal  is  to  be  thoroughly  heated.  As  hot 
as  the  patient  will  endure  is  my  maxim.  I  next  introduce  a  fine  twist 
of  absorbent  cotton,  dry,  and  I  may  here  emphasize  the  need  of 
having  a  fine  gold  or  platinum  canal-dressing  instrument,  which  should 
never  be  used  for  any  other  purpose.  Above  all  things  do  not  hope 
for  success  if  the  roughened  Donaldson  bristle  is  thoughtlessly  used 
for  introducing  a  cotton  dressing.  The  dry  cotton  having  been 
tucked  nicely  into  the  root-canal,  a  larger  ball  of  cotton  is  dipped  in 
eucalyptus  and  placed  in  the  cavity.  By  capillary  attraction  this 
agent  rapidly  passes  into  the  dressing  in  the  canal,  thoroughly  satu- 
rating it.  I  have  adopted  this  method  because  I  find  the  dry  cotton 
more  readily  carried  to  the  end  of  the  canal  than  where  it  is  charged 
with  eucalyptus.  My  white  temporary  stopping  is  then  prepared  for 
the  canal.  Softened,  it  may  be  drawn  out  almost  to  a  thread  and  is 
then  permitted  to  harden,  when  one  or  two  pieces  barely  an  eighth 
of  an  inch  in  length  are  cut  off.  The  cotton  dressing  is  then  re- 
moved, and  thin  chloro-percha  passed  into  the  canal,  a  tiny  drop  at 
a  time  on  a  smooth  Donaldson  bristle  being  worked  up  toward  the 
apex.  Next,  the  bristle  is  passed  over  the  flame,  warming  it  enough 
to  pick  up  one  of  the  little  threads  of  gutta-percha,  which  is  then 
passed  gently  up  to  the  apex  of  the  canal,  care  being  taken  not  to 
press  it  beyond,  which  would  be  indicated  by  an  expression  of  pain 
from  the  patient.     This  procedure  should  be  so  gradual  that,  should 


FILLING   OF  ROOT- CANALS.  215 

such  a  signal  be  given,  the  operator  could  stop  instantly,  no  harm 
having  been  done.  It  is  well  at  this  point  to  let  matters  rest  for  a 
minute  or  more,  that  the  filling  at  the  apex  may  become  solidified, 
after  which  the  remainder  of  the  canal  may  be  filled,  using  larger  and 
larger  threads  or  cones  until  all  is  completed.  Should  there  present 
a  case  where  there  is  doubt  as  to  whether  the  root  will  tolerate  a 
permanent  root-filling,  the  following  method  will  occasionally  serve 
a  good  purpose  : 

Take  floss  silk  and  wax  it  thoroughly,  after  which  dip  it  into 
chloro-percha  and  cut  it  into  pieces  about  an  inch  long.  These, 
when  dry,  give  us  gutta-percha  cones  which  have  a  silk  through 
them.  They  are  readily  packed  into  a  canal^  and  the  end  being 
allowed  to  extend  beyond  the  orifice  of  the  canal,  is  readily  grasped,  in 
case  of  need,  with  a  pair  of  tweezers,  whe^^eupon  the  whole  rootfilling 
is  easily  withdi'azvn.  Where  no  trouble  ensues,  the  root-filHng  of  this 
kind  may  safely  be  left  in  place,  being  quite  dissimilar  from  cotton,  as 
the  silk  fiber  is  thoroughly  incased  in  gutta-percha. 

It  may  be  argued  that  I  should  not  advocate  seemingly  temporary 
methods  ;  but  while  it  is  true  that  we  should  hope  to  make  our  work 
as  permanent  as  possible,  in  the  matter  of  root-filling,  too  positive 
permanence  is  a  detriment  rather  than  an  advantage.  It  never  can 
te  certainly  asserted  of  any  tooth  that  its  roots  will  never  need  to  be 
unfilled.  If  in  no  other  way,  the  natural  crown  may  continue  to 
decay  till  it  is  lost,  when  a  crowning  process  may  make  it  imperative 
to  empty  the  canal  or  canals.  Where  they  are  found  filled  with 
a  very  resistant  material,  there  will  always  be  some  difficulty  ex- 
perienced. Again,  I  have  seen  teeth  lost,  where  pericementitis  had  set 
in,  which  could  7iot  be  adequately  treated  because  the  root- canals  were 
so  filled  that  they  could  not  be  emptied,  the  teeth  being  too  sore  to  the 
touch  to  make  the  necessary  work  possible.  When  such  a  case  pre- 
sents the  dentist  will  quickly  say  to  himself,  "  I  wish  this  root  were 
filled  with  temporary  stopping,  which  I  could  remove  with  a  heated 
instrument."  Of  course  the  other  method,  using  the  silk-and-gutta- 
percha  cone,  is  satisfactory. 

Either  of  these  methods  require  that  at  least  a  slight  layer  of  oxy- 
phosphate  or  oxychloride  should  cover  them  before  gold  is  packed 
upon  them.  This  will  be  unnecessary  where  amalgam  is  to  be  de- 
pended upon. 

In  concluding  this  work,  I  have  only  to  state  that  in  describing  the 
methods  that  I  have  successfully  used  I  do  so  with  no  special  desire 
to  impress  my  readers  with  the  idea  that  they  are  .my  methods.  It 
seems  to  me  immaterial  who  originates  a  method.  The  main  thing  is 
that  it  be  useful.  I  have  learned  nearly  "all  that  I  know  from  others, 
and  from  experience.  If  I  can  now  teach  any  one,  it  will  be  in  some 
degree  a  repayment  of  the  debt. 


INDEX. 


Abraded  teeth,  etiology  of,  142. 

filling  of,  142. 

use  of  screws  in,  no. 
Alloys,  mixing  of,  63,  67. 
Amalgam  fillings,  finishing  of,  1S9. 

use  of  matrix  in,  49,  64. 

where  to  use  them,  65. 
Amalgams,   combination   of    with    other    ma- 
terials, 66. 

in  contour  fillings,  105,  157. 

method  of  use,  63. 

relative  values  of,  62. 

shrinkage  of,  62. 

where  to  use,  64. 
Ambidexterity,  advantage  of  to  the  dentist,  88. 
Anchorage,  difficulty  of  with  sensitive  dentine, 

135- 
Approximal  cavities,  extension  of,  16. 

preparation  of,  6,  114,  131. 

rule  for  filling,  116. 
Approximal  trimmer,  use  of  in  finishing  fill- 
ings, 1S8. 
Arrested  decay,  60. 
Arsenical  dressings,  covering  of,  185. 
Arsenical  poisoning,  treatment  of,  185. 
Artistic  work,  138. 
Automatic  mallet,  use  of,  87. 

Band,  use  of  in  filling-operations,  159,  182. 

in  restoration  of  crowns,  113. 
Beveling  enamel  margins,  27,  132,  177. 
Bibulous  paper,  control  of  moisture  by,  45. 

protection  of  gum-tissue  by,  66. 
Bicuspid  crown,  relation  of  to  the  dental  arch, 

129. 
Bicuspids,  filling  of,  96,  in,  12S,  131,  147,  175. 

roots  of,  193. 
Bite,  opening  of,  144. 
Bpnwill  mechanical  mallet,  88. 
Bottomless  cavities,  178. 
Bridge-piece,  retention  of  by  filling,  160. 
Buccal  cavities,  filling  of,  180. 
Burnisher,  use  of  in  finishing  fillings,  189. 

on  sensitive  teeth,  165. 
Burs,  caution  in  use  of,  24. 

Caries,  susceptibility  of  human  teeth  to,  89. 
Cavities,  classification  of,  114,  163. 
general   principles   involved   in   preparation 
of,  2. 


Cavities,   intentional  extension  of,  10,  14,  n.s, 
125,  130,  135,  137- 

methods  of  keeping  dry,  28. 

special  principles  involved  in  preparation  of, 
114,  136,  163. 
Cavity  borders,  formation  of,  19. 
Cement  fillings,  advantages  of,  60. 

disadvantages  of,  68. 
Cements  as  root-fillings,  213. 

modes  of  .mixing,  60,  61. 

where  to  use,  62,  82,  107,  109,  157. 
Cementum,  sensitiveness  of,  164. 
Central  incisor,  abrasion  in,  142. 

approximal  cavities  in,  94,  115. 

contour  filling  of,  104,  107. 

restoration  of  cutting-edge,  15. 

root  of,  191. 
Children's  permanent  teeth,  filling  of,  109. 
Chisel,  use  of  in  preparation  of  cavities,  150. 
Chloride  of  zinc  as  a  germicide,  59. 
Chloro-percha  as  a  root-filling,  214. 

cavity  lining  with,  58. 

control  of  moisture  by,  45. 
Clamps,  application  of,  39. 
Cocaine,  use  of  in  applying  ligatures,  32. 
Cohesive  gold,  manipulation  of,  70. 
Compound  cavities,  132. 
Contour  fillings,  burnishing  of,  80. 

manipulation  of,  91,  98. 

methods  of  producing,  102. 

use  of  amalgam  in,  64. 
Copper  amalgam,  therapeutic  value  of,  68. 
Corners,  fracture  of  by  hand-pressure,  86. 

restoration  of,  21,  119,  121,  122,  123,  131,  135, 

139- 
Cotton  as  a  root-filling,  213. 

as  a  temporary  filling,  186. 

control  of  moisture  by,  45. 

use  of  in  festoon  cavities,  31,  173. 
Crown,  misuse  of  term,  114. 

restoration  of,  in,  112,  113. 
Crown  cavities,  choice  of  materials  for  filling, 

65- 
.  enlargement  of,  155. 

preparation  of,  9,  147. 
Crystal  gold,  71,  139. 

methods  of  using,  72. 
Cuspids,  contour  filling  of,  127. 
festoon  cavity  in,  175. 

217 


2l8 


INDEX. 


Cuspids,  incisive  edge  of,  145. 

microscopical  section  of,  164. 

roots  of,  192. 
Cusps,  restoration  of  with  amalgam,  157. 
Cutting-edges,  reproduction  of,  97,  104,  121. 

Decay,  removal  of,  2,  146. 

Dental  caries,  production  of  by  micro-organ- 
isms, 3. 
Dentine,  preservation  of  in  formation  of  cavi- 
ties, 141. 
sensitiveness  of,  82,  164. 
Disk-carrier,  best  form  of,  188. 
Disks,  use  of  in  finishing  fillings,  26,  187,  189. 
Distal  cavities  in  cuspids,  128. 
Donaldson  canal-cleanser,  209. 
"Double  teeth,"  143. 
Drill,  use  of  in  root-canals,  204. 

Economy,  true  and  false,  74,  76. 
Enamel,  cleavage  of,  22. 

contact  of  gold  with,  141. 

effect  of  green-stain  on,  170. 

sensitiveness  of,  164. 
Enamel  margins,  25. 
Erosion,  caution  in  diagnosis,  166. 

distinction  of  from  abrasion,  142. 

etiology  of,  167. 

treatment  of,  169. 
Evans  clamp,  proper  use  of,  40. 

Festoon  cavities,  preparation  of,  9,  174. 

Figure-of-8  ligature,  35. 

File,  use  of,  90,  188. 

File-marks,  avoidance  of,  66. 

Filling-materials,  varieties  of,  49. 

Finishing  of  fillings,  1S7. 

Fissure  cavities,  preparation  of,  11. 

Flat  fillings,  95,  98. 

Foot-plugger,  use  of,  73,  79,  81,  103,  133. 

Fracture  of  amalgam  fillings,  106. 

Fractured  teeth,  filling  of,  36,  123,  140,  144. 

Frosted  gold  foil,  73. 

Gates-Glidden  drill,  204. 

Germicides,     combination    of   with    oxyphos- 

phates,  61. 
Gingival  border,  failure  of  fillings  at,  41,  65, 

128,  132. 
Gold  as  a  filling-material,  69,  130. 

as  a  root-filling,  212. 

combination  of  with  oxyphosphate,  81. 

contour  fillings,  102. 

how  to  condense,  85. 

incorporation  of  with  amalgam,  64,  66. 

unsuitable  cases  for,  179. 
Gold  and  iridium,  85. 
Gold  and  platinum,  83. 
Gold  and  tin,  84. 
Gold  fillings,  finishing  of,  187. 

for  crown  cavities,  65. 

leakage  of,  4  ,  66. 

use  of  matrix  in,  48. 
Gravitation,  effect  of  on  fillings,  118,  122. 
Green-stain,  170,  1S2. 
Grinding-surfaces,  reproduction  of,  96. 


Grooved  incisors,  treatment  of,  15. 
Grooved  teeth,  illustrations  of,  168. 
Gum-recession,  root-exposure  from,  184. 

tooth-sensitiveness  from,  163. 
Gum-tissue,  arrangement  of  in  man,  90. 
Gutta-percha  as  a  filling-material,  56, 186. 

as  a  root-filling,  214. 

choice  of  colors,  57,  185. 

cones  for  root-filling,  215. 

finishing  of,  189. 

Hand-Mallet,  advantages  of,  87,  175.    - 
Hand-pressure,  danger  of  fracture  by,  121. 

in  gold  fillings,  85,  121. 
Hart,  J.  I.,  on  sensitive  dentine,  165. 
Heavy  foil,  manipulation  of,  80,  103. 

uses  of,  77,  132,  175. 
Heitzmann,  C,  microscopical  section  of  cuspid, 

164. 
Hollow  fillings,  78,  102. 
Horse-shoe  grooves,  151,  178. 
How  cervix  clamp,  41. 
How  screws,  use  of,  no. 
Hypersensitive  teeth,  gold  fillings  in,  82. 

Incisive  edges,  cavities  in,  136,  144. 

contouring  of,  141,  145. 
Incisors,  filling  of,  15,  92,  104,  107,  no,  in,  115 

143- 
root-filling  of,  191. 
Infected  dentine,  3. 
Instruments,  use  of,  89,  175. 
Interzonal  layer,  sensitiveness  of,  165. 
Iridium,  combination  of  with  gold,  85. 

Knots,  methods  of  tying,  33. 

Labial  cavities,  filling  of,  79,  116, 120,  133,  176. 
Lateral  incisor,  proneness  of  to  abscess,  126. 

root  of,  192. 
Lead  as  a  filling-material,  50. 

as  a  root-filling,  212. 
Leakage  of  fillings,  41,  66. 
Ligatures,  different  forms  of,  32. 

slipping  of,  38. 
Lingual  cavities,  filling  of,  379. 
Loose  teeth,  filling  of,  34. 

fixation  of,  162. 

Mallet,  choice  of,  87,  175. 
Mastication,  effect  of  on  the  teeth,  92. 

fracture  of  fillings  by,  106. 
Matrices,  uses  and  dangers  of,  47,  129,  187. 
Milk,  production  of  green-stain  by,  170. 
Miller,  W.  D.,  on  green-stain,  170. 
Mixing-slab  for  oxyphosphates,  60. 
Moisture,  devices  for  controlling,  45. 

in  contour  work,  106. 

recurrence  of,  42. 
Molar  crown,  relation  of  to  the  dental  arch,  129. 
Molars,  enlargement  of  cavities  in,  12. 

filling  of,  95,  109,  112,  134. 

roots  of,  208. 
Mouth,  examination  of,  148,  153. 
Mouth-mirror,  use  of,  118,  120,  121. 
Muffle  for  porcelain  work,  54. 


INDEX. 


219 


Napkins,  use  of,  44. 

Nitrate  of  silver,  use  of  on  sensitive  teetli,  166. 

Non-cohesive  gold,  use  of,  70. 

Oven  for  baking-  porcelain,  54. 
Oxychloride  of  zinc  as  a  filling-nialenal,  58. 
Oxyphospliate  of   zinc,   combination   of   with 
amalg-am,  67. 

combination  of  with  gold.  Si,  93,  157,  179. 

finishing  of,  1S9. 

in  contour  work,  107. 

in  crown-setting,  61. 

in  festoon  cavities,  173. 

manipulation  of,  60. 

Palatal  cavities,  filling  of,  178. 
Palato-approximal  cavities,  filling  of,  120,  133, 

180. 
Pellets  for  small  cavities,  116,  iSi. 
Pettit  reamer,  207. 

Phosphate,  combination  of  with  amalgam,  67. 
Pin-head  fillings,  improper  use  of,  12. 
Pipe-clay  disks  for  control  of  moisture,  45. 
Plastic  gold,  advantages  of,  71. 

combination  of  with  amalgam,  67. 
Platinum,  combination  of  with  gold,  83. 
Pluggers,  choice  of,  SS. 
Polishing,  best  methods  of,  26,  1S7,  189. 
Porcelain  fillings,  50. 

anchored  with  gold,  55. 
Porcelain  inlays,  50. 

Power  mallet,  unsuitable  places  for,  140,  175. 
Pressure,  influence  of  on  gold,  S6. 

line  of,  107,  152. 
Probational  fillings,  1S4. 
Pulp,  retention  of  dentine  over,  146. 

size  of  determined  by  age,  134. 
Pulp-capping  with  gutta-percha,  58. 
Pyorrhea  alveolaris  resulting  from  wedging,  91 . 

Reamer,  use  of  in  root-canals,  207. 
Retaining-points,  122,  126,  133,  152,  181. 
Retentive  shaping  of  cavities,  5,  130,  137. 
Root-canals,  methods  of  cleansing,  209. 

preparation  of,  202. 

when  and  how  to  fill,  212. 
Root-filling,  difficulties  of,  190. 
Roots,  exposure  of  from  gum-recession,  184. 
Rose  bur,  use  of  in  preparation  of  cavities,  1 15. 

125,  131-  136,  137.  140,  143- 
Rubber  cup,  use  of  in  finishing  fillings,  1S8. 
Rubber-dam,  placing  of,  29,  43. 


Rubber-dam,  repair  of,  44. 

Rubber  tubing,  use  of  in  festoon  cavities,  31, 

173- 
Rubber  wedge,  use  of,  46. 

Sandarac  varnish,  objections  to,  185. 

Saucer-shaped  cavities,  7,  78,  135. 

Screw-mandrel,  advantages  of,  188. 

Screws,  use  of,  109,  123,  124,  133,  144. 

Secondary  dentine,  formation  of,  59. 

"  Self-cleansing"  surfaces,  17. 

Separators,  abuse  of,  45,  129. 

Silk  and  gutta-percha  cones,  215. 

Sixth-year  molar,  filling  of,  109. 

Soaping  disks,  44. 

Sodium    and    potassium    treatment    of    root- 
canals,  210. 

Space,  necessity  for  in  filling-operations,  129, 
130. 

Sulci,  reproduction  of,  96. 

Surface  cavities,  167. 
rarity  of  in  incisors,  173. 

Syringe  for  cleansing  root-canals,  210. 

Tape  separators,  46. 

Teeth,  change  in  position  of,  97. 

decalcification  of  by  green-stain,  1S3. 

occlusion  of,  90. 

separation  of,  90. 

shortening  of  bj-  abrasion,  143. 

union  of  by  a  single  filling,  160. 
Temporary  fillings,  1S4. 
Temporary  stopping,  use  of,  56,  185. 
Tin  as  a  filling-material,  50,  184. 

comb'nation  of  with  gold,  84. 
Tooth-brush,  effect  of  on  tooth-structure,  165. 
Tooth-neck,  sensitiveness  of,  105. 
Tooth-roots,  varj'ing  forms  of,  190. 

Undercuts,  filling  of,  75. 
use  of  in  preparation  of  cavities,  7, 9, 304, 115, 
122,  127,  152. 

V-space,  injurious  results  from,  91. 

Watts's  crystal  gold,  71. 

"  \Vea\ing"  method  in  ligatures,  37. 
I  Wedges,  use  of,  45. 

Wheel-bur,  use  of  in  extension  of  cavities,  136. 
I  Williams,  J.  L.,  theory  of  dental  caries,  3. 
j  Wisdom-teeth,  roots  of,  201. 

Wood  as  a  root-filling,  212. 
I  Wooden  wedges,  47. 


Ot8 
1899 


